Free Essays

Free Health and Safety Assignment


Health and safety is of paramount importance. Essentially, this is an issue of growing importance anchored in the ministry of labour. It is important to note that pollution and odor nuisance may be detrimental on the local environment quality. As such management of the working environs becomes a necessary and fundamental aspect. This paper presents an analysis on pollution, health and safety aspects with respect to a case study on food hygiene inspection in derelict town.

Main hazards

Following the inspection process a number of potential hazards were noted. First, the kitchen floor was stained with large and slippery grease patch which may result in injuries due to unexpected major impact in case of a fall. Second, the unit lacked grills and filters which were responsible for blocking the hydrocarbons that form when fat drips into fire. Their absence may pose mutagenic and carcinogenic effects hence a major hazard (Moeller, 2003). Third, the dumb waiter seemed to be out of order. Finally, behind the bar was a patch of water which remained unclear where it came from. Perhaps, this was responsible for the musty smell emanating from the pub.

Legal provisions

The employer/business owner is obligated by the law to ensure health and safety on the environment. “The provision and use of work equipment 1998” provides minimum standards for use, maintenance and protection of equipment (Farmer, 2007). Similarly, “The provisions on health and safety regulations 1992” sets out measures that prevent repetitive injuries due to slippery floors. Finally, there is a legal provision on nuisance covered under “Noise at work regulations 1989” that imposes a duty on the premises owner as a result of excessive noise and nuisance (Watson, 2010).

Enforcement tools

“The Health and Safety at Work Act 1974” is the primary legislation that governs safety in the work place (Mioshi, Ferrett & Hughes, 2009). Similarly, “The Control of Pollution Act 1974” is another piece of legislation that controls pollution and make provisions with regard to waste disposal, public health and atmospheric pollution. Finally, “The Environmental Protection Act 1990” acts as an enforcing tool that empowers the local authority with the duty to investigate complaints of various nuisances arising on trade, industrial and business premises that may be prejudicial to health.

Preferred approach

A certificate of safety should be provided with relevant health and safety legislation on dumb waiter. Grills and filters need to be installed to minimize hazardous effects. Regular cleaning and drying of the floor should be done to prevent bad odor. Finally, a risk assessment needs to be conducted to ascertain whether reasonable steps and abatement measures have been taken. These will ensure compliance with the relevant legislation and enforcing standards on pollution, health and safety.


Mioshi.C, Ferrett.E & Hughes.P (2009), Introduction to health and safety at work, Butterworth-Heinemann publishers, 4th edition

Watson.P.S. (2010), Safety, health and environmental auditing: a practical guide, CRC Press

Moeller.D (2003), Environmental health, Harvard University Press

Farmer.A (2007), Handbook of environmental protection and enforcement: principles and practice, Earthscan Publications Ltd

Free Essays

Food Health & Nutrition Dissertation Topics

1. Introduction to Food Health and Nutrition

This guide gives you some ideas for dissertation titles. Food Health and Nutrition covers many areas, so there should be plenty to whet your appetite here.Dissertations typically take one of two forms, focusing either upon collecting and analyzing primary data or upon appraising secondary data only. Either type can be appropriate to your area of study. You will also find an overview of how to structure your dissertation in section three below.

2. Categories and List of Dissertation Titles

2.1 Food, Nutrition and Public Health

2.1.1 To what extent is legislation around food and nutrition designed to serve the interests of large corporationsA comparison of recent policies in the UK and USA.

2.2.2 What impact have recent advances in nutrigenomics had on public health policies, and what potential does it have to change such policies in the futureA review of literature.

2.1.3 Safe upper limits: have guidelines from the Food Standards Agency produced in 2003 recommending safe limits for a number of vitamins been incorporated into the public awarenessA quantitative study amongst over 50’s UK women.

2.1.4 Food and nutrition: does class count Does the knowledge of the link between obesity and diet vary between socio-economic groupsA qualitative study amongst parents of school children in the UK.

2.1.5 Can the concept of household food security (HFS) offer an adequate tool for investigating attitudes towards nutrition and foodA review of recent literature.

2.1.6Is an interdisciplinary and partnership approach the best way to tackle the growing problem of obesity in the UKA literature review.

2.1.7 Can food policies in school shape parent’s and children’s attitudesA qualitative study in an inner London comprehensive school.

2.1.8‘Good food is too expensive and hard to find’: Do women living in poverty in the inner city find choices about food most limited by education, geographical location, unemployment or lack of fundsAn qualitative study using techniques of action research.

2.2 Global Food Issues

2.2.1 To what extent are emergency food programmes successful in reaching those people most in needA critical analysis of three recent responses to emergency food situations after natural disasters.

2.2.2 Is an integrated global policy on food health and nutrition more possible now than in the twentieth centuryA review of the literature.

2.2.3 What is the impact of inflation upon nutritional health in developing countries A literature review.

2.2.4 To what extent do concepts of health differ from country to countryA quantitative study assessing attitudes towards notions of ‘eating well’, ‘a good diet’ and ‘food that is good for you’.

2.2.5 How effective have zinc supplements been in improving health in developing countriesA ciritcal review of the World Health Organisation’s recent policies, priorities and programmes.

2.2.6 Women: poorly served in healthWhat impact does gender have on nutrient deficiencies worldwide A qualitative study amongst healthcare workers in developing countries.

2.2.7 What impact does foreign direct investment have on problems of nutrition and diet within the developing worldA review of recent literature.

2.2.8 A Mediterranean diet for health: can eating the traditional diet of Mediterranean regions have a positive impact on weightA quantitative study.

2.3 General Food Health and Nutrition

2.3.1 Can a case be made for a vegetarian diet in terms of the long-term sustainability of farming and animal productsA literature review.

2.3.2 To what extent do the elderly suffer poor diet and nutritional deficiencies in UK care homesA review of the literature.

2.3.3Does consumer understanding of sustainability impact upon food choicesA qualitative study amongst buyers in a UK supermarket.

2.3.4 What is the relationship between the obesity epidemic and sustainabilityA systematic review of the literature.

2.3.5 Can educational interventions offer a way to increase biodiversity in foodA quantitative study amongst UK school children.

2.3.6Wild plants and traditional medicine: to what extent do UK residents originally from Eastern Europe use foraged plants medicinally, and is their knowledge dissiminated amongst other UK residentsA qualitative study.

2.3.7Home grown bacon or children’s petWhat prompts decisions to slaughter home-bred pigs, and are these mitigated by the views of children in the familyA qualitative study amongst 10 families who bought pigs to raise and slaughter for meat.

2.3.8 What is the most effective way to develop a sustainable food supply and avoid malnutrition worldwide A qualitative study amongst experts around the world.

2.4 Food, Nutrition and the Consumer

2.4.1 Consumer perceptions of non-Polish users of specialist Polish food retailers in the UK: is there a relationship between previous travel habits and use of Polish food retailersA quantitative study in Crewe, Cheshire.

2.4.2 Eat healthy: which factor is more influential in choice of food products associated with health – colour, labeling or layoutA qualitative study amongst UK consumers using action research techniques.

2.4.3Is there a link between consumer recall of nutritional labeling information and the effective use of such information A quantitative study.

2.4.4 Do people who exercise regularly read food labeling information more frequentlyA qualitative study amongst members of a running club.

2.4.5 Does the perceived attractiveness of other eaters in a restaurant influence customers towards more healthy or lower calorie choices from the menuA quantitative study in three London restaurants.

2.4.6 Nutrigenomics: a new way of personalizing nutrition, or a passing fadA review of recent literature.

2.4.7 Is purchase behaviour regarding functional foods linked to socio-demographics of consumersA quantitative study amongst shoppers in Tesco.

2.4.8 Is there a relationship between willingness to have surgical treatment for obesity and use of food nutrition labels amongst female consumersA quantitative study amongst morbidly obese women in the UK.

2.5 The Science of Food

2.5.1 Is there adequate evidence that soy phytoestrogen supplements sold commercially have a positive impact upon depression and anxiety in humansA systematic review

2.5.2 To what extent do extraction methods impact on the ability of components of Elettaria cardamomum seeds / pods to produce antioxidant and antimicrobial effectsA review of recent literature.

2.5.3 Can taking Selenium reduce the risk of prostate cancer in menA systematic review of literature.

2.5.4 Has the suggested link between eating garlic and reduced risk of cancer been proven, and, if so, by what mechanisms is this reduced risk possibleA literature review.

2.5.5 Can experiments on animals which suggest that endogenous peptide YY3-36 (PYY3-36) can regulate appetite have implications for the treatment of problems of over-eating in humansA literature review.

2.5.6 Is the evidence that the by-products of coffee decaffeination (crude caffeine) has antioxidant properties sufficient to use it for health benefits, and, if so, what is the most effective way of using itA review of the literature.

2.5.7 Are organically farmed livestock able to offer superior products in terms of biometric and nutritional propertiesA quantitative study comparing meat from organic and non-organic producers.

2.5.8 Another ‘superfood’ Can Maqui Berry extract be used to treat type II diabetes in humansA review of the literature.

3. How to Structure a Food & Health Dissertation, Tips

For details on how to structure a marketing dissertation, kindly check out the following post:

How to Structure a dissertation (chapters)
How to structure a dissertation (chapters and subchapters)
How to structure a dissertation research proposal

Free Essays

Health and Social Care Dissertation Topics


1. Introduction to Health and Social Care Dissertation

A Health and Social Care study is aimed at providing a multidisciplinary course towards an academic qualification in the health and social care area which is grounded on social sciences. Contrary to alternative disciplines which emphasize upon clinical training, the focus of Health and social care studies is upon the social experiences and understanding of health and social care, including assessment and evaluation of key trends and evidences, informing, monitoring and evaluating programs and interventions, the policy issues and delivery and management of services. The research in health and social care area tends to focus upon the real needs of communities.

Here are a list of health and social care categories within which you can base your research:

2. Categories and List of Dissertation Titles

The subjective purpose of the health and social care research necessitates a debate regarding the ethical and methodological challenges associated with primary research within this field. Apart from research methods, some of the key areas in health and social care research includes: problems related to children and youth; health and social care systems and policies; issues such as ageism, substance abuse, violence, and mental and physical disparities; and the right for health. The following is a list of titles within these areas from which you can choose you own dissertation topic.

2.1Research Methods

2.1.1 Ethical Challenges Associated with Health and Social Care Research

2.1.2 Ethical and Methodological Challenges Associated with Primary Research Related to Physically and Mentally Challenged People

2.1.3 An Overview of Ontological View and Epistemological Position of Social Sciences Research

2.2Problems of Children / Maltreatment against Children

2.2.1 Impact of Maltreatment upon the Development of Child & Adolescent. Outlining an Intervention Strategy for Underdeveloped Societies

2.2.2 Bullying Prevention and Intervention Strategies for Children with Disabilities; Assessing its Prevalence and Identifying Risk and Protective Factors

2.2.3 Prevalence of Neglect and Violence against Children with Hyperactivity Disorder

2.2.4 The Impact of Racial and Ethnic Discrimination upon the Development of Children of Minority Groups in (any heterogeneous society)

2.2.5 An Overview of Factors that Contribute to Child Neglect; A Comprehensive Literature Review of Risk and Protective Factors and Intervention Strategies

2.3Social Services / Inequality / Poverty / Social Justice

2.3.1 Social Inequalities and the Exposure to Environmental Risk Factors in Terms of Health in UK

2.3.2 An Examination of a Social Pattern in Environmental Risk Exposure Among Various Risk Groups in an Underdeveloped Country

2.3.3 The Reformation of Pension System in China (Or any Other Country Which is Undergoing Social Services Reforms)

2.3.4 In Depth Case Studies of Charitable Foundations Providing Basic Health and Social Care Services in Pakistan

2.3.5 The Impact of Racial and Ethnic Discrimination upon Minority Groups in India; Risk Factor for Health Disparities

2.3.6 Assessing the Financial Sustainability of Health Care System in UK; Recommendations for Policy Making

2.3.7 Development of an E-Commerce Learning Disability Service; A Feasibility Report for a Service Similar to E-Bay for Social Care Service Providers and Users.

2.3.8 Reviewing the Social Policy Changes in UK throughout its History Century; An Analysis of Literature


2.4.1 The Impact of Technology on Social Life in Modern Times; Impact upon Generational Division

2.4.2 Evaluating the Financial Sustainability of Health and Social Care System of an Ageing UK

2.5Substance abuse

2.5.1 Determining Measures that can Reduce Recidivism in Substance Abuse Patients

2.5.2 Strategies to Reduce Recidivism after Rehabilitation in Substance Abuse; Case Study of Successful Interventions

2.6Right to Health

2.6.1 An Overview of Occupational Health and Safety Management System in an Underdeveloped Country; The Absence of Local Health and Safety Standards Among SMEs

2.6.2 Determining the Factors that Affect the Prescription Tendency of Doctors in (Any Locality)

2.6.3 Developing a Framework for Evaluating Ethical Marketing Practices in Pharmaceutical Marketing

2.6.4 Does Visual Exposure to Greenery has Positive Physiological and Behavioral Impact

2.6.5 Examining the Associations between Workplace Environment Design in Term of Greenery and Employee Well-Being

2.7Mental and Physical Disparities

2.7.1 An Evaluation of Intellectual, Emotional, Physical and Social Benefits of Creative Play for Disabled Children

2.7.2 Documenting Alternative Accounts of Life after Physical Impairment; Reflecting a Positive Social Identity Following Impairments

2.7.3 Exploring the Personal Narrative of an Athlete’s Journey to Paralympics; Achieving International Sporting Success after a Life Changing Accident

2.7.4 An Overview of Literature Regarding Methods for Teaching Social Skills to Children with Asperger’s and Autism

2.7.5 Correlation between Unpleasant (Polluted) Living Conditions and Personality Disorders

2.7.6 Social Stigma Related to Depression; Evaluating the Public Perception Regarding the Causes of Depression and its Impact on Treatment Seeking Attitudes

2.7.7 Depression: A Global Health Concern; Analyzing the Most Common Onsets of Depression in UK

2.8Policies Related to Immigrants

2.8.1 An Assessment Health and Social Care Services Provision to Immigrant Labor force in UAE

2.8.2 The Impact of Social-Economic Inequalities upon the Development of Children of Immigrants in UAE

2.9Violence; Interpersonal / Women

2.9.1 Determining the Prevalence and Factors that Lead to Domestic Violence against Women in UK in the 21st Century

2.9.2 Reintegration of Ex-Combatants (Soldiers Returning From Afghanistan or Iraq) into the Social Fabric; Recommendations for Policy Making and Developing Specialized Social Care Services

2.9.3 Assessing the Consequences of Normalization of Domestic Violence against Women in Terms of Social and Mental Development

2.9.4 The Impact of Gender Discrimination upon the Development of Young Girls in Traditionally Conservatives Societies

2.10 Problems of youth

2.10.1The Correlation between Gender, Religion and Self Actualization, and Death Anxiety in Young People

2.10.2Youth Violence in UK; Identifying Risk Factors and Evaluating the Effectiveness of Prevention Strategies

Free Essays

Health, Safety & Environmental Management.


We are living in an era described as an environmentally conscious age, where every deed acted by humans in terms of development, the effect is being weighed in relation to our environment. Consequently this has prompted a substantial number of environmental regulations being endorsed to hold business organizations more accountable for their environmental responsibilities. These policies tend to focus on tackling such problems from the source, with the knowledge of how certain insignificant decisions taken by such organizations can have a detrimental effect on the environment as a whole. (Darnall et al 2008).

One of the strategies adopted by these organisations was to introduce a tool known as Environmental Management System (EMS) that can be used to achieve a high degree of environmental protection within the context of sustainable development. (Bansal and Bagner.2002). This tool was first developed by the British Standards Institute (BSI) identified as BS7750 published in 1992. By 1994 the European Commission published another management tool known as Eco-Management and Audit Scheme (EMAS).

According to Bansal and Bagner after an increasing demand for improved environmental performance by the United Nations, the International Organization for Standardization (ISO) was mandated to create an internationally recognised environmental management system called ISO 14001 which is being used up to date.

Over the years EMS has been seen as part of a policy frame work for establishing any type of organisation from Schools, hospitals to even shops. However, within the years researchers are beginning to question the authenticity of EMSs since organisations claim to have one, when infact they make no attempt to reduce their environmental damage. “In instances where EMSs enhances an organization’s environmental performance, critics argue that improvements are likely to occur within the organization’s operational boundaries rather than being extended throughout the supply chain.” (Darnall et al 2008).

Despite these emerging misconceptions EMS has been effective in reducing environmental impacts within and outside the organisations especially as fines and penalties are being enforced on non compliance of organisations by the regulatory bodies.


This report will focus on EMS and how it relates to Eco campus, a tool established by Glasgow Caledonian University to regulate its environmental impacts. Furthermore, it will look at the positive and negative aspects of adopting an EMS, and the evidences of bronze and silver medals won by the GCU through implementation of eco campus and the steps towards achieving a Gold medal.


According to Coglianese and Nash an EMS can be described as a set of in-house policies, reviews, plans and functioning actions affecting the entire organization and its relationships with the natural environment. They went on further to say even though the specific institutional description of EMSs differ across organizations, all EMSs entail setting up an environmental policy or plan which goes through internal evaluations of the organization’s environmental impacts including computation of those impacts and how they have changed over time, creating quantifiable goals to reduce those environmental impacts, providing resources and training workers, checking implementation progress through systematic auditing to ensure that goals are being reached, correcting deviations from goal attainment and undergoing management review. Absolute incessant improvements are done on the model, which are anticipated to help organizations insert environmental practices deep within their operational frameworks so that protecting the natural environment becomes a fundamental component of their overall business strategy (Shireman, 2003).

Environmental management systems function under the Shewart and Deming cycle of continual improvement which can be actualized by a step by step procedure. . It is repetitive and based on the PLAN – DO – CHECK – ACT system. First of all, a re-evaluation of the institution is done and a plan is set out on how the review made can be improved. Next is to develop how to execute the plan and once the system has been implemented, it is verified frequently to see if it is performing successfully. Finally, any suggestions for improvements are implemented. The cycle then begins again so that the system is repeatedly improved and refined to have room for future changes. ( The figure below illustrates the process further.



Presently there are quite a few recognizable standards in Environmental Management Systems, but most the recognised and certified are the:

ISO 14001: 2004 International Standard for Environmental Management.
Eco – Management & Audit Scheme (EMAS).
IEMA – Acorn Scheme.


2.1.1 ISO 14001:

ISO14001 objective is necessitating an organisation to implement an Environmental Policy within the organisation fully supported by the top management, and outlining the policies of the company, not only to the staff but to the public. The policy has to be in conformity with Environmental Legislations that may affect the organization and stressing a commitment to continuous improvement. Emphasis should also be placed on policy as this provides the direction for the remainder of the Management System. (Hillary 1999). Furthermore, ISO 14001 has grown at a very fast rate, and has gained acceptance as the “model T” among management systems perhaps not as a flashy or advanced as others, but prescriptive, reliable, affordable (in terms of cost and effort) and perhaps most importantly it gets you there.


The EU Eco Management and Audit Scheme recognized as EMAS is a voluntary market based instrument designed to inculcate better environmental performance from all types of organisations. EMAS has also been intended to completely be well-suited with international standard for environmental management systems ISO 14001, but goes further in its requirements for performance improvement, employee involvement, legal compliance and communication with stakeholders. Uniquely EMAS requires organisations to produce an independently verified report about their performances. (

2.1.3 IEMA – Acorn Scheme:

It has been mentioned by the Institute of Environmental Management and Assessment (IEMA) that Acorn Scheme is an officially accepted EMS standard suggested by the government, which offers a suitable step by step approach to environmental management using the British Standard BS8555. IEMA also described the scheme as a coherent practical tool that contains five stages of EMS implementation. Each stage is further subdivided into other individual stage profiles which match up to the schemes principle.


Eco campus has been defined by the ecocampus website as both an environmental management system and an award scheme for the higher education sector. The scheme allows institutions to be acknowledged for adopting certain sustainable key issues. The main aim of the eco campus scheme is to encourage, reward and provide tools to assist institutions in moving towards environmental sustainability through good operational and management practices.

The eco campus programme consist of four phases; Bronze, Silver, Gold, and Platinum. By working through these phases, the university will -:

– Renew its current environmental performance and plan how it can be improved.

– Develop procedures to implement the plan

– Check actual progress

– Ensure any recommendations for improvement and implement them.

The Eco campus like the EMS, share the same objectives which is to inculcate, promote and integrate steps, ideas, plans that have less effect on the environment. In terms of implementation Eco campus works in the same manner with the EMS which is the application of the four key steps “Plan- Do-Check-Act” and off course with the criteria of continual improvement. Basically an eco campus is a tool that helps institutions achieve sustainability through an EMS approach, the relationship being an eco campus is an EMS with a different name because it functions in an institutional organisation. The only difference between the two would be the award winning criteria your institution tends to gain by adopting eco campus, whereas EMS does not reward implementation especially in that manner (bronze, silver, gold and platinum).


The eco campus award criterion is based on the PLAN – DO – CHECK – ACT system and these four stages are awarded sequentially by the four medals assigned by the scheme. Bronze (planning), Silver (implementing), Gold (operating) and Platinum (checking and correct).

The bronze phase basically complements the “planning” and this has to do with how devoted the senior management are towards attaining a sustainable institution. Environmental awareness, training, baseline environmental reviews and drafting an environmental policy are the main key elements of the bronze phase. An institution must be able to show these four basic commitments before they can be certified a bronze worthy.

The Silver however is referred to as “implementing” and it requires the execution of the elements highlighted in the policy. It`s key elements include: legal and other requirements, significant environmental aspects, objectives, targets, programmes, and environmental policy.

The gold is recognised as “operating” and consist of resources, roles and responsibilities; competence, training and awareness; communication; documentation and control of documents; operational control; emergency preparedness and response.

Finally the platinum which is the checking & correcting requires monitoring, measurement of the success so far followed by the evaluation of compliance in terms of abiding by the restrictions placed & the non conformity, correctiveness, and preventive action. Furthermore control of records is required, internal auditing and finally the management review.(GCU Envirocampus, 2007)


According to Glasgow Caledonian University/sustainability website EMS has the following beneficial qualities:

assists in obtaining a licence to operate and complying with legal and other requirements such as planning consents;
improves relationships with regulators;
helps to prevent enforcement or civil actions;
reduces hidden costs associated with legal action (including substantial draw on management time);
avoids fines and damages awarded from legal action through criminal or civil courts
improves operational and process efficiency;
reduces operating costs and resource use thereby increasing profitability;
reduces outlay on waste disposal;
gives the institution a long-term sustainable future;
develops relationships with stakeholders by satisfying investors’ lenders’ and insurers’ environmental performance requirements;
helps to obtain insurance at a reasonable cost;
enhances the internal and external image of the institution, making it more marketable;
helps attract and retain quality staff and students;
Reduces pollution and improves the environment.

And EMS has the following drawbacks:

requires human and financial resources;
takes time to convince people that it is worthwhile;
requires good communication and training;
can be time-consuming to implement and maintain

From the above mentioned list, it clearly signifies how the advantages of an EMS overshadow the disadvantages, and for an effective and organised improvement of an institution’s environmental activities, it is most recommended.


According to the GCU/Sustainability website on June the 12th 2009 Glasgow Caledonian University received a bronze medal. It was presented by the eco campus Director, Dr Peter Redfern of Nottingham Trent University to Jim McQueen who received it on behalf of Glasgow Caledonian University eco campus team during workshop number 5 at Bournemouth University on the 1st of July 2009. It was on a time scale of 2 and 3 month and it covered the “planning stage”. It had an upfront cost of ?9000 for purchase of training tools. These tools are: – web trainer tool, review tool, significance calculator tool and document control tool.

The silver medal was later awarded on the 28th of April 2010 after successfully completing the “implementation stage”. The certificate was presented to Therese Fraser and Jim McQueen on May the 18th 2010 at Nottingham Trent University in correspondence to their Workshop 9 attendance. This was undoughtedly accomplished based on the commitments the staff and students of GCU had put in. Presently, the institution focuses on programmes to reduce carbon dioxide emissions under the supervision of the university in areas such as administrative, accommodation, and leisure buildings. It also has in place a carbon management plan which was approved by the carbon trust on 30th April 2010. (

As part of their commitment towards creating a sustainable and carbon free campus, GCU has joined the carbon trust scheme in addition to the eco campus plan. Besides that, their commitment goes as far as reducing their adverse impacts on the environment under the mandate set up by the Scottish government which involves an action to reduce carbon dioxide emission and to the climate change Bill 2007, commitments has been made to reduce emissions nationally by 69% by 2050. The School is also committed to promote projects which enhance society’s management of waste through collaborating with an environmental body that utilizes landfill tax credits called SCORE. (

In terms of drafting an environmental policy under the bronze criteria GCU have been active in that department, a lot have been drafted but just to mention a few. The policies include:

Incorporate recycling initiatives within our waste management review, increase recycling by 5% year on year.
Develop the use of recycled materials and increase recycling initiatives.
Prevent pollution by reducing emissions and discharges.
Reduce the negative impacts associated with our travel by 4% in this year while developing partnerships with travel groups.
Reduction in water by 10% over the next 2 years by increasing automatic metering.

As mentioned in the policy document, it is underpinned by the values of the University and is subject to annual review by the Executive Board which is also another criteria for award attainment (environmental reviews) together with “implementation” of these plans which is the silver stage. The university achieved this through its collaborative effort between the EMS manager and certain specialists in each area of GCU. They reviewed aspects like electricity which has severe negative impacts especially as it is produced by burning fossil fuels. (

Regarding the issue of awareness, trainings & workshops, GCU has achieved a lot in that area quite a number of awareness weeks & trainings have taken place like its carbon footprint programme that was held on Environment day May the 5th. Other awareness campaigns followed such as facilities management department held an Environmental & Energy awareness day on Thursday November 1st 2007. Amongst them the most successful one that took place was the Energy awareness day of September the 19th 2006. It was estimated that over 1,000 staffs and students passed through the exhibition.


The Gold phase of the eco campus covers “operating” as mentioned earlier and is depended upon the institutions commitment. Operating consists of the following:-

– Resources, roles, responsibilities and authority;

– Competence, training and awareness

– Communication

– Documentation

– Control of documents

– Operational control

– Emergency preparedness and response. (eco campus Audit criteria 2005-2008)

1. Resources, Roles and Responsibilities

The university will have to provide evidence of appropriate resources put in place in order to implement the environmental management system. Roles and responsibilities should be allocated to member staffs and students; this will enable the institution to finalise the outline management structure.

2. Competence and Training

All training records shall be collated, recorded and stored. Assessment shall also be made on the competency of persons whose work may have a significant impact on the environment. Both staff and students especially those that are part of the eco campus team should have adequate training to ensure they understand the environmental issues relating to the institution and their roles and responsibilities for implementing the environmental management system. The same Training should also be done to any new persons joining the team and all training should be recorded and updated.

3. Communication

Procedures must be adopted for documenting and responding to environmental communication received from within and outside the institution. This can be achieved through presentations, briefings, lectures etc and key environmental impacts and relevant legal issues should be communicated to team members. Also, roles and responsibilities should be communicated to all relevant persons in order to meet the commitments made in the environmental policy and objectives and targets

4. Documentation/Control of documents

The institution shall develop an EMS manual describing how the EMS operates and cross referencing to relevant documentation. A procedure for controlling environmental management system documentation shall be established. This entails -documents shall be defined.

i- An authorised person shall approve system document prior to release and the date of approval shall be shown on the document.

ii-Record of changes made to documents shall be maintained.

iii- Responsibilities, authorities and processes for disposing of absolute documents shall be defined.

iv- An authorised person shall approve system document prior to release and the date of approval shall be shown on the document.

5. Operational Control

Having control over all operational activities is a vital role in achieving the Gold medal. This can be made possible by looking at the guide as follows:-

A procedure should be developed to outline the management of operational control procedures; procedures that address significant aspects in line with objectives and targets should be developed. These procedures shall demonstrate how the institution controls those areas of its activities which could have an effect on the environment.

6. Emergency Preparedness and Response

System to identify and respond to emergencies which could result in damage to the environment must be put in place. A schedule of emergency procedure test drill should be established, this will help to describe how the institution review and test emergency preparedness and response.

Glasgow Caledonian University through some of its activities like being part of the carbon trust and the commitments to sustainability and creation of greener campus has already tackled some of the basic elements listed above. However, there is still more to be done to ensure the institution becomes a sustainable institution. Some key issues like waste management and creating awareness through campaigns still needs to be addressed. Most students are either not aware or refuse to comply with the waste management strategy. There seem to be a waste segregation and recycling that is going on but due to lack of awareness most of students do not know therefore, there is still much that has to be done in order to attain the Gold level and achieve a sustainable university. And a target for that should be the international students which GCU has quite a few, source segregation for example needs to be made aware especially during the first weeks of orientation about how it works and its importance. Water management and electricity consumption is another issue that needs to be addressed, motion light sensors and water meters should be installed in hostels because that is where most of the consumption takes place. Students should be enlightened on the impacts of such actions and the need to develop a secure, safe and sustainable institution for learning. I also recommend placing parking ticket fee or stamps to parking spaces this will help reduce emissions from staff and students from coming with cars and at the same time make subsidies and promos on bus fares to school.


All institutional activities have an impact on the environment and there is need to review our mannerisms if we are committed in reducing the effects. This can best be achieved through the incorporation of an environmental management system which appears to be the most logical and effective way. The success of the systems without a dought takes a little while to be actualized but there are a lot of gains attached to it, such as the Eco campus award schemes, National Recognitions, an efficient structured management system and above all the Management of our Environment. And again the success as mentioned in the report requires the devotion of the People within the organisation. So it is about time Government Steps in and make EMS a more Standardize requirement for organizations especially schools where most of the daily activities occur in terms of resources usage.

Caledonian Environmental Centre (CEC): 2007; implementing an environmental management system in Glasgow Caledonian University
Coglianese, C. Nash J.2001. Regulating from the Inside team can Environmental Management system Achieve Policy Goals Washington: Resources for the future Press.
Darnall, N. Henriques,I. Sardosky, P.2008. Do Environmental Management systems Improve business Performance In an International SettingJournal on International Management, 2008, 14, pp364-376
Eco campus Audit criteria 2005- 2008; Available on blackboard via health and safety assignment materials
Ecocampus. (2010). Ecocampus [Online]Available at:[ Accessed on 4 November 2010]
GCU.(2010). Sustainability[Online] Available at : http//[accessed 3 November 2010]
Hillary, R. (1999). Evaluation of Study Reports on the Barriers, Opportunities and Drivers for Small and Medium Sized Enterprises in the Adoption of EMSs. London: Network for Environmental Management and Auditing. Paper submitted to UK Government. Department of Trade and Industry: Environment Directorate (5/10/99).
Institute Of Environmental Management & Assessment.[Online] Available on[Accessed 3 November 2010].
Shireman W. 2003. A Measurement Guide to Productivity: 50 Powerful Tools to Grow your Triple Bottom Line. Asian Productivity Organization: Tokyo

Free Essays

Exploring Literature Review and it Significance to Present Health and Social Care

Chapter One


The aim of this assignment is to undertake a secondary research in exploring literature review and it significance to present health and social care. Clinical question will be formulated with rationale given for choice of topic by undertaking an extensive review of the literature. Following the systematic search, the student will critically evaluate literatures and other evidenced based information in order to discuss and answer the question. The design methods and data analysis will be discussed. It will also consider evidence based practice and the applications of research studies on nursing practice. Producing a dissertation that draws conclusion and makes recommendations for nursing practice will be deliberated.


This chapter will introduce the background of the review, its rationale, research question, aims and objectives.


The World Health Organisation (WHO, 20010) defines obesity as a complex condition, one with serious social and psychological manifestations that affects virtually any age and socioeconomic groups and threatens to overtake developed and developing countries. Obesity is the commonest form of malnutrition and is reacting epidemic proportions in developed and undeveloped countries around the world (Wadden et al. 2002). Arterburn et al. (2008) also defines obesity as a chronic condition characterised by an excess of body fat. It is often diagnosed in adults by using the Body Mass Index (BMI), which is calculated by measuring weight in kilograms and dividing this figure by height in metres squared (kg/ m?) ( Shepherd, 2009). Individuals with BMI ranging from 25Kg/m? indicate overweight whiles 30+ kgm? indicates obesity in adults. Overweight occurs when energy intake exceeds energy needs. Weight gain occurs when individuals for whatever reasons overeat or under exercise (Ahearne – Smith, 2008).

Obesity is a complex, costly and debilitating condition. The health implications of obesity are vast and the cost of treating this condition is a burden on the NHS, in terms of finance and resources. (Department of Health (DH) 2009a). Estimates put the cost of treating obesity and its associated complications at over one billion pounds per year in the UK, this figure is predicted to rise to ?45 billion by the year 2050 (Wintour, 2007). Research has estimated that in England, 6.8% of all deaths attributes to obesity (NHS, 2010). A recent study looking at data for 27 year period concluded that about one quarter of deaths in England was directly or indirectly related to obesity (Duncan et al. 2010). Predicted trends in obesity amongst men and women in England extrapolated to 2010 indicates that 26% of men and 28% of women will be clinically obese, imposing huge burden on the healthcare (National Audit Office, 2001).

Evidence indicates that there is a complex interrelationship between genetics, environment, childhood, family and non genetic factors (Kipping et al. 2008). There is also growing body of evidence that describes obesity as a polygenic disorder, with many genes being linked to or associated with a predisposition to adiposity (Batch and Baur, 2005). One of the latest genes to be associated with an increased risk of obesity is the fat, mass and obesity gene (Loos and Bouchard, 2008), which is thought to confer a predisposition to the disease through the control of food intake (Cecile et al 2008). Cairns and Stead (2009) discusses the increase in weight as a reflection of the trend in the western world generally and has been attributed to an abundance of food combined with disposition towards less physical activity of our daily lives. It further explains the diminished physical activity stems not only from changing employment patterns, but also from the many aids available to the average house holder, the ubiquitous motor car, and trends in the design of buildings and cities.

Obesity is a chronic metabolic disease, considered to be one of the main risk factors for cardiovascular disease and correlating with increased morbidity and mortality (NHS, 2010). Research shows that there is a link between excess body fat and the risk of developing a number of serious disease including diabetes, hypertension, cerebrovascular disease, arthritis and some cancers (Swain and Sacher, 2009). It has been confirmed that overweight individuals decreases their risk of premature death by doing physical activity even if their weight doesn’t change. People who are overweight can be limited in their ability to carry out physical activity because of reduced oxygen uptake capacity and painful muscles and joints. This limitations in locomotive power influences movement behaviour and lead to problems in activities of daily living.

Weight loss reduces blood pressure and improves metabolic profile. It also reduces the symptoms and improves several obesity related chronic conditions such as diabetes, obstructive sleep apnoea and osteoarthritis (SIGN, 2010). Weight loss is also associated with improvement of vascular morphology and function. Research by Pierce et al. (2008) demonstrated that short term, energy intake restricted weight loss alone is an effective intervention for improving endothelial function in obese subjects.

The impact of being overweight and obese has been studied from the perspective of health related quality of life (HRQL). Although, there is no standard definition of HRQL, It is generally accepted that it is subjective, multi dimensional assessment of the physical health, emotional wellbeing and psychosocial functioning (Hassan et al. 2003). There is also a growing body of cross – sectional data that support strong relationship between obesity and quality of life, in that quality of life tends to decrease as function of weight increase. Literature also supports that even small weight reduction leads to significant improvement in HRQL (Fontaine and Brofsky et al. 2001). Results of meta-analysis on the effects of randomised controlled trials of weight loss on HRQL using variety of intervention methods (behavioural, surgical, pharmacologic) suggest that the most consistent effects are found only when using obesity specific measures of HRQL (Masiejewski et al. 2005).

In addition, the majority of the studies in HRQL changes in obese and overweight individuals have focused on major medical techniques such as gastric bypass surgery and pharmacotherapy. Although these may be important strategies and options for obese individuals, the majority of populations are more likely to attempt behavioural programme focused on changing their dietary and exercise behaviours (Fontaine and Bartlett, 2001). There have been relatively few studies that have examined the effects of lifestyle modification programs on changes in quality life among overweight and obese individuals. Physical activity in combination with can be effective in improving health related quality of life in social functioning, mood and self esteem.

Many literatures exist on the effects of diet and exercise with no clear agreement on their long or short term efficacy. However, it is unclear if weight loss improves risk factors in all obese persons or only in high risk groups. Finally, it is important to determine if weight loss studies are applicable to everyday clinical management for these patients.


The aim of the literature is to ascertain the long and short term effects of weight loss management programme (dietary, exercise and behavioural modification) on health related quality of life for patients with obesity problems.

To assess the clinical effectiveness and cost effectiveness of weight loss management.

To explore the long term effects of obesity treatment on body weight, risk factors for disease and quality of health and its benefits to the individual.


The salient research question for the review is: ‘’Does structured weight reducing programme improve the quality of health for patients with obesity?. The weight reduction programme will focus on the non-pharmacological aspects of weight reduction programme which are diet, exercise and behavioural changes.


The rationale for the choice of topic has been influenced by dominance in the media recently with regards to cost to the society in treating patients with obesity and co – morbidities associated with the condition. The role of the nurse involves educating and promoting the health of individual clients or patients in terms of weight management. The writer has also developed an interest in gaining knowledge and understanding of the conditions and interventions for promoting weight loss as some form of management in enhancing patient’s quality of life. Undertaking this research would add to the students knowledge and, hopefully to provide some answers to the research question.




This chapter will document the methods used to identify literature relating to the aims of the review. Also, how the literature search was conducted as well as the inclusion and exclusion criteria used in identifying relevant articles will be presented. Outcomes of the literature search and a presentation of the data will be included (Appendix 1).


Partaking in evidence-based practice require the ability of nurses to evaluate and gather best available evidence, and integrate them into clinical practice and individual expertise (Burns and Grove, 2011). The fundamental purpose of literature review is to identify a broad spectrum of relevant information on a specific topic and develop a robust appraisal of its methodology and research designs to highlight any inconsistencies of the literature (Hewitt-Taylor, 2002). Many authors including Aveyard (2007) defines it as a systematic search and interpretation of a particular research area which adds to the implementation of evidence based protocols. Similarly, Hek et al (2002) explains it as a process of literature search and guiding of a topic to reveal ‘gaps’ in the current knowledge. Aveyard’s definition will be utilised for the purposes of this review as through systematic searches, relevant articles will be scrutinized for current knowledge and development of how healthcare professionals can effectively use evidence based in promoting the health of patients (Aveyard, 2007).

Some research studies may however have misleading findings due to their destitute research design, thus a critical appraisal tool would be used to critically appraise and disregard such evidence and provide findings from robust studies (Katrak, 2002). The appraisal tool chosen for the review was the Critical Appraisal Skills Programme Tool (CASP, Public Health Resource Unit, 2006). The CASP tool comprises a list of questions which enables the findings, study design and sample of research studies to be critically assessed and evaluated (Katrak et al, 2004). The CASP tool was chosen due to its simple guidance in critically appraising research studies while assessing its applicability and validity. Also both quantitative and qualitative research may be influenced by confounding variables, thus the CASP Tool helps to highlight variables that may reduce the validity of the results (Burns and Grove, 2011; Hurley et al, 2011).

Literature Search

Healthcare literature forms the basis of a great deal of work that nurses do, therefore searching and reviewing literature is a key skill as it helps to locate new initiative in its context and to examine new ideas (Steward, 2004). Literature search was used to device an evidence based question. Literature search is a structured approach to search information, producing the best available evidence for informing and guiding practice (Parahoo, 2006). Computers and electronic databases were used to undertake the literature search. This offered access to vast quantities of information, which could be retrieved more easily and quickly as compared to the manual search (Younger, 2004).

Data were gathered from literature search using the following databases, MEDLINE, COCHRANE, CINHAL, EMBASE, SYNERGY, OVID etc. Using specific electronic databases with the help of the librarian enabled the student to identify which databases were relevant to the topic or subject area. The selected database contained indexes of journal in the medical sciences, in addition to nursing, midwifery and related disciplines in retrieving a wider range of quality and relevant research to demonstrate wider reading and awareness of available databases. Some of the databases such as MEDLINE and COCHRANE library had some restrictions in accessing full text articles.

An initial search of the literature was used in narrowing down the process of topic selection. The following words were used for the search: obesity, overweight, training, exercise, physical activity, behaviour, adult, weight loss. This type of search highlighted many areas that could be exploited and conducted. Timmins and McCabe (2005) explains that using the initial search to identify a topic may gain an advantage over others because it gives certainty that there are recent and accessible published researched on a topic. Once the area of interest had been decided, a more focused and detailed search was used in incorporating many different sources. Burnard and Newell (2006) suggest that comprehensiveness and relevance are what reviewers needs to consider and adds that more specific the topic or question been search is, the more focused the results will be. Alternate key words with similar meanings such as bariatric patients, weight management were gleaned from databases and thesaurus to help elicit further information. Hek et al. (2002) states that the key principles for guiding literature search are being systematic, explicit, thorough and rigorous.

Boolean and truncating operators was also incorporated in searching for the literature by expanding, excluding or joining key words using ‘AND’ or ‘NOT’. These operators instruct the search engine to combine specific and necessary element within the last ten years (2001 – 2011) were utilised to enable the student to narrow and obtain the most recent articles relevant to the formulated question. The search was also extended to other countries because of limited articles in the UK and its applicability to the subject area. The inclusion criteria for the literature review are as follows: the study had to be researched articles, the subjects had to be adults, diet, exercise and behaviour modification had to be part of the treatment, the subjects would be overweight or obese. The inclusion and exclusion criteria also involved the first read of the articles that have been collected to get a sense of what they are about. Most of the published articles contained a summary or abstract at the beginning of the paper, which assisted with the process and enabling the decision as to whether it is worthy of further reading. Cohen (1990) framework for undertaking systematic review was adapted to aid with the process of narrowing and choosing the articles relevant for the research question proposed. This method involves the preview, question, read, summarise (PQRS) system kept the student focused and consistent but ultimately facilitated me with easy identification and retrieval of materials, leaving me with articles that were deemed relevant to the purpose of the review.

A total of 12 relevant articles were obtained after the literature search and with the application of the inclusion and exclusion criteria, only two articles were from the United Kingdom. The rest were from Australia, Holland, Netherlands, Canada and America. They all addressed the aims as well as the research question. All the articles were selected on the basis of its abstract, title, year and its relevance to research question. A summary of search history and findings of reviewed articles are presented in Appendix 1. Timmins and McCabe (2005) summary of grid table would be used to put the data extracted into chronological order and also into different classification can be seen in appendix 2. In order to be able to compare treatment outcomes from the different groups in the studies, the effect size will be used to analyse the studies intervention effect with reference to weight loss. In evaluating the literature, the systematic approach literature will be divided into classification and themes and presented chronologically.




This chapter explores the key findings of the selected research articles and provides a critical analysis of the research methodologies and findings. They will be presented as themes and will be compared and contrasted to reveal any ‘gaps’ or inconsistencies in the literature.


The aim of Jehn et al study was to examine the long-term effects on weight maintenance and dietary habits of participants in a clinical trial weight loss. Forty – four hypertensive overweight men and women were randomised in a comprehensive ‘lifestyle intervention’ group or monitoring group for 9 weeks. Participants in the ‘lifestyle intervention were fed hypo caloric version of the Dietary Attempts to stop Hypertension Diet (DASH) and also participated in a supervised moderate intensity exercise programme three times a week. The dash diet is rich in fruits, vegetables and low fats dairy products, and reduced in saturated fat, total fat and cholesterol. It has also been shown to substantially lower blood pressure in normotensive and hypertensive individuals (Appel et al 1997). Participants were provided all their meals. The monitoring group received no active intervention during the study but did receive up to three sessions of nutrition and lifestyle counselling following completion of data collection. One year following the completion of the DEW-IT trial, 44 participants were contacted for a single follow up visit. Participants were weighed on a certified balanced bean scale, and completed two brief dietary questionnaires in assessing reason for participating in the trial, changes in diet and exercise following participation and perceived barriers to maintaining weight loss. Wilcon test and t- test were used to compare groups for differences in continuous variables and chi square test were used to compare categorical variables. 42 of the original 44 participant returned for the 1 year follow up visit (n=23 for monitoring group and n=19 for the lifestyle group). The results showed weight loss at the completion of the study averaged 5.3kg in the lifestyle group and 0kg for the monitoring group. The intervention group in comparison to the monitoring group achieved significant improvements in their blood pressure and lipid profiles. Interestingly, 95% of the lifestyle intervention group and 52% of the monitoring group gained weight at the end of the study although, they both reported similar intakes of fruits and vegetables.

Leslee et al (2009) however conducted randomised clinical trial, using diet and exercise programme to reduce incontinence and to determine whether behavioural weight reduction intervention for overweight and obese women with incontinence would result in greater reductions in the frequency of incontinence episodes at 6 months as compared with control groups. 338 women were recruited between July 2004 and April 2006 in Alabama and Rhode Island. Women were eligible for the study if they were at least 30years of age, had body mass index of 25 – 50kgm? and at baseline reported 10 or more urinary incontinent episodes in a 7 day diary of voiding. The participants were required to monitor their food intake and physical activity for a week, to be able to walk unassisted for two blocks without stopping, and to agree not to initiate new treatment for incontinence and weight reduction for the duration of the study. Eligible participants were randomly assigned at a 2:1 ratio to an intensive 6 month behavioural weight loss programme or to a structured four session education programme (control group). Random assignments were concealed in tamper proof envelopes, the participants were aware of their treatment but the staff members who collected data were not. This helps to reduce the possibility of selection and study bias, thereby increasing the reliability and validity of the results (Polit and Beck, 2008). However, the cost and time pressures of undertaking RCTs compared with other research methodology may limit their feasibility or restrict recruitment. The participants completed questionnaires concerning their demographic characteristics, medical and behavioural history and history of incontinence. The subjects were weighed and height recorded. They were also trained to complete a 7day dairy of voiding. All participants were given a self-help behavioural treatment book with instructions for improving bladder control such as information about incontinence and pelvic floor exercises. Women assigned to the control group were scheduled to participate in four education sessions at months 1, 2, 3, 4. The participants in the weight loss group were provided with meal plans, encouraged to gradually increase physical activity. The results showed that the women in the intervention group had a mean weight loss of 8.0% (7.8kg) as compared with 1.6%(1.5kg) in the control group. After 6 months, the mean weakly number of incontinence episodes decreased by 47% in the intervention group, as compared with 28% in the control group. As compared with the control group, the intervention group had a greater decrease in the frequency of stress incontinence episodes (p=0.01), but not of urge incontinence episodes (p=0.14).

Obesity is associated with increased arterial stiffness, an early marker of vascular wall damage. However, data on the long-term vascular impact of intentional weight loss are limited. Goldberg et al (2008) aimed to evaluate the effect of weight loss induced by nutrition and exercise intervention on arterial compliance, metabolic and inflammatory parameters in obese patients who participated in a weight reduction programme. An open, prospective study, 37 obese subjects attended a 24weeks nutritional and exercise interventional programme. During the course, participants received diet instruction and participated in physical training once a week. Arterial elasticity was evaluated using pulse wave – contour analysis at baseline and end of study. Fasting glucose, HbA1C, insulin, lipid profile, hs-CRP, fibrinogen were measured. BMI Decreased from 36.1±7.4kgm? at baseline to 32.8±7.4kgm? after 6months. Large artery elasticity index increased from 12.1±4.1 to 15.8± 4.7ml/mmhg?10 during the study. Small artery elasticity index also showed an increase. There was significant improvement in fasting hyperglycaemia, HbA1C and significant decrease in LDL cholesterol, fibrinogen and C-reactive protein. Goldberg et al concluded that moderate weight loss induced by nutritional and exercise intervention improved small and large artery elasticity. The increase in arterial elasticity was associated with improvement in glucose and lipids homeostasis as well as markers of inflammation.

Obesity may affect lung function and so cause worsening of asthma. The mechanism by which weight loss can alleviate asthma may include alleviation of the airway collapse, stimulation of adrenal activity, and reduction in possible allergens, bronchoconstrictors or salt content in the diet (REF). Aarniala et al (2000) investigated the influence of weight reduction on obese patients with asthma. The design is an open study, two randomised parallel group in a private outpatient centre in Helsinki, Finland. Two groups of 19 obese patients with asthma (BMI=30-42kg?) recruited through newspaper advertisements. Base line measurements were taken and randomised to treatment group (19) or control group (19) by shuffling cards with the help of someone not involved in the study. The treatment group took part in a weight reduction programme included 12 group sessions, which lasted for 14wks, including 8weeks dieting period. The control group had sessions at the same intervals as the treatment group. All participants used normal medical care throughout the year. A peak flow metre and spirometer was used to measure their daily morning and evening pre bronchodilator and post bronchodilator peak expiratory flow, FVC, FEV as baseline, during the dieting period, at the end of dieting period, at 6months and 1yr. Data were analysed by means of start view 512+TM (brainpower) for apple Macintosh and SPSS. Mean weight reduction in the treatment group was 14.2kg of their pre-treatment, the control 0.3%. The corresponding figures after one year were 11.3% and weight gain of 2.2% for the treatment group. For the treatment group, health status improved with respect to all three subscales when compared with controls. By the end of weight reduction programme, reduction in dyspnoea in the treatment group was 13mm and 1mmin the control group. There were minimal exacerbations reported in the treatment group than in the control group. Aarniala et al concluded that weight reduction in obese patients with asthma improves lung function, symptoms, morbidity, and health status.

Similarly, Shawn et al (2004) prospectively studied 58 obese women with a body mass index of >30kgm?, 24 of whom had asthma, were enrolled in an intensive 6month weight loss programme to, whether loss of body mas would be correlated with improvements in bronchial reactivity, lung function, and disease specific health status. Patients were placed on a regime of three liquid meal replacement supplements per day, which delivered 300 kilocalories per meal. Those with severe obesity were enrolled into a long programme consisting of a diet of 900kcal per day that continued for twelve weeks. Patients were assessed in series of three paired study visits. Symptoms and disease specific quality of life were assessed using the St. George respiratory questionnaire (SGRQ) at baseline and every three months for duration of the study. The results showed that patients lost an average of 20kg over the 6 month period. For every 10% relative loss of weight the FVC improved by 92ml, and FEV1 improved by 73ml. However, bronchial reactivity did not significantly change with weight loss (p=0.23). Patients who lost > 13% of their pre-treatment weight experienced improvements in FEV, FVC and total lung capacity as compared to patients in the lower quartile who failed to loose significant amount of weight. Patient who completed the programme experienced improvements in respiratory health status.

Syed et al (2008) sought to identify the effect of weight reduction program on right and left ventricular structure and function. 62 patients presenting to the eating disorder clinic at a single academic institution for weight loss programs were prospectively enrolled. Subjects BMI were greater than 30mg/m? and attempting to lose weight by diet and exercise. Baseline and follow up transthoracic echocardiograms were obtained after at least 10% weight reduction or 6 months after baseline echocardiogram. Patient lost an average of 28±3kg over a period of 266±36days. Left ventricular mass index decreased significantly from 255.87±12 to 228±11gm. There were no statistically significant changes in contractility or diastolic indices. The ratios of early to late diastolic mitral inflow and annular velocities also increased. The results of the study concluded that weight reduction is associated with decreased in the ventricular diastolic size and left ventricular mass. However, the weight reduction did not associate statistically significant improvement in systolic or diastolic function.

Contrastingly, Kaukua et al (2003) studied health related quality of life in a clinically selected sample of obese patients. The study was carried at two obesity clinics at Helsinki University Central hospital. General occupational practitioners or hospital specialist referred all patients for weight loss treatment. Referral criteria included a body mass index ?35kgm?, failure of previous weight loss attempts, presence of obesity related comorbidity requiring weight loss and motivation to take part in a structured weight loss programme. An endocrinologist examined the patients and evaluated suitability for treatment. Patients were excluded if they had obesity due to secondary aetiology, had significant psychiatric disorders, severe eating disorders, and were eligible for bariatric surgery. The treatment comprised 10weeks on very low energy diets (VLED) and 17 weekly group visits with behavioural modification. The eight groups in this study were carried out during 1999 – 20000. The behaviour modification programme was on LEARN programme for weight control. The core elements of behaviour modification were goal setting, nutrition etc. Anthropometry assessments were used to measure the patient’s height, weight with calibrated electronic scale and calculated the BMI whiles the obesity specific questionnaires measured the obesity related psychosocial problems in everyday life. SPSS 10.0 was used to analyse all data. The Helsinki University central hospital and Peijas hospital ethical committies approved the study protocol and the informed consent form, which subjects sign after having received written and oral information. The results of the 126 patients who received treatment showed that the mean BMI did not differ from sexes. But the mean waist circumference was significantly larger in men. There was also decrease in obesity related psychosocial problems at the end of therapy and this improvement was maintained up to 2yrs despite weight regain. There was also large increase in physical functioning, improvement in body pain and general health, but not all the scale showed statistical significance relative to base line.

The study selection process outlined identified 8 studies. There was fair or good agreement for study inclusion suitability and data extraction. To summarise, all the eight research articles received ethical approval from the ethics committee to protect the rights, dignity and safety of the study participants. Consent was also gained from the subjects before participating in the research. They also had clear aims, methods, findings and conclusions.

Chapter 4


4.1 Purpose of chapter

This chapter will give a detailed discussion of the prime findings highlighted whilst comparing and contrasting evidence. An interpretation of the themes will be made as well as evidence-based recommendations for future management, practice and education. The focal research question was: ‘’Does structured weight reducing programme improve the quality of health for patients with obesity


This review has provided an alternative lens in understanding the importance of weight management and weight loss in improving the health of these patients as well as reducing it cost to the health service in managing this condition.

Weight reduction requires energy expenditure to exceed dietary energy intake. Despite a considerably amount of research dedicated to understandingthe role of diet in mediating weight control, there still remains disagreement regarding basic issues including the appropriate energy content, and perhaps more controversial, the ideal macronutrient distribution. Manipulation of the energy content will impact the rate of weight loss. Very low calorie diets will result in larger, more rapid reductions in weight loss, whereas a small to moderate reduction in energy intake will result in a small, steady rate of weight loss. The pertinent question becomes: does the rate of weight loss affect long term weight maintenance or other health related outcomes?

In most of the studies the subjects had lost significant amount of weight by the end of the intervention period. Some of the studies also indicated weight gain. There was significant weight loss in all groups. In Jehn et al (2006) study of weight loss intervention demonstrated the effectiveness of short term intensive programme of diet and exercise in blood pressure control. However, significant amount of weight gain occurred also in treatment group and consequently, weight at the 1 year follow visit did not differ between the treatment and control groups. Similar finding was also found in Kaukua et al single stranded 2 year follow up study of diet, exercise and behaviour modification for weight loss management. The patients in their study produced marked weight loss (12.5%) and wide range of improvements in health related quality of life in the short term. However, with longer follow after treatment, weight loss maintenance on average was only modest with mean regain of two thirds weight lost in 2yrs.Interestingly to weight loss, the improvements in health related quality of life started to diminish after 2 year. On average, only obesity related psychosocial problems and physical function showed improvements. Not only weight loss, but other factors such as therapeutic effects of taking part in a weight loss programme or increase in exercise and physical activity promoted by behavioural modification, might have been the cause of improved the quality of live as in the studies reviewed(reference).

Among overweight and obese women with urinary incontinence, the comprehensive weight loss programme in Leslee et al (2009) resulted in a significantly greater reduction in the frequency of self-reported urinary incontinence episodes as compared with the structured education programme. Higher proportion of women in the weight loss group than in the control group reported clinically meaningful reduction of at least 70% in the total weekly number of episodes of any incontinence, stress continence and urge incontinence. In addition the women in the weight loss group perceived greater improvements in their incontinence and were more satisfied with their improvements. These results suggest that overweight or obese women with stress, urge or mixed incontinence may benefit from weight loss. It has been hypothesized that obesity may contribute to urinary incontinence because of the increase in intraabdominal pressure due to central adiposity, which in turn increases bladder pressure and urethral mobility, exacerbating stress incontinence and possibly urge incontinence (Stewart, 2010). Weight reduction may reduce forces on the bladder and pelvic floor, thus reducing incontinence as a result from changes in dietary intake and physical activity (Subak et al. 20005).

Obesity is not only disproportionate gain of weight, rather it is a complex metabolic process associated with hypervolumic state, elevated pressures and dyslipidaemia. It is also associated with elevated cardiac output mainly produced by high stroke volume. Elevated stroke volume along with an expanded total blood volume presents an elevated preload to the left ventricle (reference). In Syed et al (2008) study, significant weight loss of 28.29±3kg was associated with decreased left ventricular mass, wall thickness, and diastolic dimensions. The beneficial changes were accompanied by preserved left ventricular systolic function. Contrary to the expectation, the observed decline in left ventricular wall thickness, and left ventricular mass did not translate into improved diastolic function or significant reduction in left atrial size. Instead, they observed increased early transmitral inflow velocities and decreased diastolic myocardial relaxation velocities. Left atrial dimensions decreased, but this does not reach statistical significance which represents that there is no decline in the size of left atrium. In Syed at al study, none of the findings are associated with improved diastolic function. This may represent that ventricular stiffening that leads to diastolic dysfunction associated with obesity may be less reversible than the other parameters. An explanation given to the lack of improvement in diastolic function is perhaps due to the short duration of the study or inadequate number of patients in the study. A larger study of longer duration will be neededto verify the myocardial mechanical abnormalities suggested by their study.

In contrast to Syed et al study, Goldberg et al (2008) study moderate weight loss induced by nutritional and exercise intervention was associated with improved small and large artery elasticity. The increase in elasticity was associated with improved glucose homeostasis and lipid profiles together with a reduction in the markers of inflammation. In response to a mean weight loss of 8% observed during 6month follow up, both small and large arterial elasticity increased significantly. Moreover, subjects who lost >10% of baseline body weight had significantly greater large arterial elasticity values and lower insulin resistancecompared to patients who did not lose or lost <5% of baseline body weight. In obesity, arterial stiffening is consistently observed in across all age groups and may contribute in part to excess cardiovascular morbidity and mortality. These harmful vascular effects may be mediated by comorbidities linked to obesity such as hypertension, dyslipidaemia, insulin resistance and diabetes. Recently, it has been demonstrated that excess body fat, abdominal visceral fat, and larger waist circumference have been associated with accelerated stiffening independent of blood pressure levels, ethnicity and age (Sutton-Tyrrell et al 2001). These results emphasize the adverse effects of obesity on the arterial wall and suggest that this effect is reversible with weight reduction.

Aarniala et al (2000) trial showed that in obese people with asthma, losing weight can improve asthma in terms of lung function, symptoms and health status. Several possible explanations exist for this improvement in asthma during and after weight reduction. In asthma airway obstruction causes early airway closure during expiration. This feature is accentuated by overweight. Weight reduction reduces closing capacity and exercise load which may alleviate asthma symptoms during exercise (reference). Although, general symptoms and lung function improved in the treatment group, use of rescued medication remained unchanged. This may reflect the fact that, whereas overall clinical picture of the asthma was improved by weight reduction, airway hyperactivity persisted.

Some strengths of the review were the use of randomised trials which can increase the reliability of the results, allowing the researchers to compare changes in weight between the intervention group and the control group that did not receive an intervention. Additionally, the researchers used actual weight rather than self-reported weight which has been shown to be unreliable for reporting long-term weight maintenance. Furthermore, participation for the follow up was good. This minimises the potential bias that those who volunteered to participate were more likely to have been successful at weight maintenance (Jehn,2006). The studies also indicate that without on-going contact, structural support and reinforcement of health goals, individuals are unable to maintain weight loss one year after intervention. Further research is needed to determine whether adding more intensive nutrition, education components and or cognitive behavioural therapy to dietary feeding trials can produce successful long-term weight maintenance.

In this review we included those three components that have been shown to be most important factors in weight loss; exercise, diet and behaviour modification. In view of the foregoing, the aims and research question of the review has been successfully answered and a wider understanding of the importance of weight management in helping to prevent morbidity and mortality of obesity. In addition to the findings, it also appears from the above that diet, exercise and behavioural modification has significant effects in managing weight loss and reducing obesity. Clinicians have to be skilled in eliciting and promoting the health of these individuals to prevent morbidity and mortality (ref)


The main limitations of the studies are the small sample size, impeding the ability to examine predictors of weight change in multi variant analyses. A major limitation of this review was the use of researched articles from America, European countries as well as other Non – European countries such as Australia where the delivery of care differs from that of the United Kingdom and what may appear as important to American patients may not be important to that of the United Kingdom. Furthermore, the use of only published articles, poses the risk of publication bias as most journal articles do not deliberate on the ‘negative or no effect’ thus hidden evidence that is vital in synthesising the findings application of research question may be missed (Aveyard, 2007).

Limiting the exclusion and inclusion criteria from studies published from 2000 to 2011 meant that any valid research before that had to be excluded, thus any significant findings relevant to the review may have been overlooked (Jokinen et al, 2002). Although an attempt was made to retrieve recent data, literature into obesity and weight loss management commenced around the 1960’s thus it is a broad topic and not all relevant research studies could be included in the review (Verhallen et al, 2004). Lastly, financial restrictions were also a limitation of the review as most journals required membership or a fee to retrieve articles thus useful articles for the review may not have been attained.


Adequate research has now been gathered to demonstrate diet, exercise and behaviour modification is important in the effective management of weight loss for patient with overweight or obesity problems. Eliciting the health concerns of these patients and the cost to both family and society in this review has demonstrated the urgent need to address the quality and effectiveness of the weight induced programme in improving the health of these patients in order to reduce the comorbidities associated with the condition.

The level of motivation in overweight individuals probably plays a very important role in the success or failure of weight treatment. Factors that influence motivation include the degree to which overweight individuals receive support from their families, advice and information from healthcare professional that can also set up realistic goals through continuous contact.


According to the present review, the treatment of overweight and obesity that promises the best results consist of diet, behaviour modification and exercise. Treatment with exercise alone cannot be expected to any significant weight loss, regardless of the type exercise. On the other hand, exercise can be important factor when it comes to preventing continued weight gain or maintaining lower weight even in the long-term. Thus this review reached an important conclusion that the treatment of overweight individuals requires a multidisciplinary approach. This approach means that representatives from all professions, dieticians, behavioural scientist, psychologist, psychotherapist, nurses, physical therapist and doctors must collaborate with each other

Free Essays

If You Don’t Ask Me…Don’t Expect Me to Tell: A Pilot Study of the Sexual Health of Hospice Patients


Problem Statement and Purpose.

Sexual health of Hospice patients has been an important issue of discussion devoted to the overall quality of care that patients are exposed to. Many issues have risen pertaining to poor communication between healthcare providers and hospice patients on this subject. Many nurses do not feel very comfortable talking with the patient about his or her sexual health. Likewise, patients do not open up about their needs especially at the time when their passing is near. In the Pilot Study of the Sexual Health of Hospice Patients, the purpose of this study was to determine the views of hospice patients and nurses regarding sexual health and their relationships.

Review of Literature.

This research project aimed to (1) identify the current status of hospice patients’ concerns regarding sexual health and (2) document the perceptions of hospice nurses regarding their understanding of the patients’ concerns regarding sexual health. The breakdown of this data indicated that a comprehensive assessment and understanding of sexual health in the life of the patients was needed. The findings showed that hospice patients lacked these needs even in the final stage of their disease.

Theoretical Framework.

The theoretical framework for this study was the Sexual Health Model. The model reflects the human sexuality in ten categories to determine healthy sexuality. The ten components of this model are: discussion about sex, culture and sexual identity, sexual anatomy and functioning, sexual healthcare, overcoming challenges to sexual health, body image, masturbation and fantasy, positive sexuality, intimacy and relationships, and spirituality and values. These aspects of sexual health were implied in the study in all areas to find out what intimacy and sexual health were to the patient and provider. When compiling this study many questions and hypothetical statements were drawn. Though the field of scope was very broad the main two hypothetical questions were met to be evaluated. (1) What are the perceptions of hospice nurses regarding the sexual health needs of hospice patientsand (2) what are the sexual health needs of hospice patientsThese questions are addressed and studied throughout the procedure for evidence of sexual health communication between nurse and patient.

When setting up this study, the author implemented several methods that attributed to the feedback that was researched. In this pilot, cross-sectional, survey-design study, the author (M.M.) constructed a series of structured telephone and in-person interviews with a sample of hospice nurses and patients regarding issues of sexual health. This research study was approached in two forms. The first part aimed at documenting perceptions of hospice nurses regarding their understanding of their patients’ concerns regarding sexuality and intimacy; the second part focused on hospice patients’ perceptions and needs regarding sexual health. For both nurses and patients, written consent was obtained from each participant, and then demographic information was obtained from the various individuals. To assume a effective, corresponding relationship steps were followed to promote efficiency: (1) all interviews were carried out by the same researcher; (2) interviews were performed in the patient’s home to verify there everyday experiences and attitudes; (3) all interviews were accomplished with the researcher taking notes throughout the interview process; (4) Individual inspection occurred throughout the interviews, which consisted of the researcher restating, summarizing, and paraphrasing the individual’s information to ensure that the research notes were precise ; and (5) the research team implied the data with frequent checks for reliability.

Methods and Sample Populations.

In the study, Nurses were evaluated first on their reasoning of dealing with sexual health situations with hospice patients. Data was collected using open-ended in-person or telephone interviews. The author (M.M.) identified individuals by starting with five hospice nurses at an agency where they were formerly employed and used snowballing to identify 15 others. Diversity was brought into interviewing nurses from two geographically states, Oklahoma and New Hampshire. Nurses chose to participate in the study when asked. The nurse interview questions were detailed and designed to bring forth current practices regarding assessing of sexual health. The results obtained showed that the nurses had a couple of areas that needed refinement in for proper assessment of patient. The interviews with hospice nurses revealed six issues regarding sexual health: (1) lack of assessment, (2) sensitivity of the matter, (3) topic lacked priority, (4) patient characteristics were of significance, (5) no assessment standard, and (6) area not covered in their nursing education.


A majority of nurses did not assess their patient’s sexual needs, but every nurse at least knew of one of their patients showed a need for intimacy. A lot of the nurses also said the issue with these findings was of lack of assessment and not a priority at the time. To end the study, many of the nurses said that this issue was not covered in their nursing education, causing for a ineffective assessment of patients needs.

The second part of the study reviewed how hospice patients categorized sexual health and how the relationships between them and the nurse were brought about with this topic. This study used standard assessment tool to identify the current status of hospice patients’ concerns regarding sexuality and intimacy. Hospice patients were interviewed using the 100-item WHO Quality of Life Assessment questionnaire formed to assess sexuality and intimacy. A method of sampling was used for hospice patients who met certain criteria for the project. The selection consisted of meeting with hospice nurses to explain the study and ask for help in recruitment. Patients who qualified for the study were those enrolled in hospice, assessed by the hospice nurse to be cognitively intact, and able to hear. Individuals signed a consent form, and were told that participation was voluntary.

The following questions were measured on a 5-point Likert-type scale: (“How would you rate your quality of life?”), (“Are you satisfied with your opportunities for sexual contact and closeness?” and “level of intimacy in your life?”), (“How satisfied are you with your personal relationships?”), and (“How would you rate your sex life?”; “How well are your sexual needs fulfilled?”; and “Are there any difficulties in your sex life?”). Each of these (ranking 1-5) was followed by an open-ended question asking the participants to tell the interviewer more about their view of the question. The patients ranged in age from 37 to 97 years; 53% were women and 47% were men. Thirty-four percent of the respondents rated their sex life as poor or very poor, while 60% were satisfied with the level of intimacy in their life.


Many of the hospice patients just needed someone to open up to them about their sexual health. Nurses need to know that sexual health is just important in hospices patients as with the concept of dying in their homes or areas of care. Assessing an individual about the possibilities of their sexual health could implement harmony and excitement instead of pain throughout the end of their life.

As hospice patients since that the end of their life is near, it is extremely important as a nurse that you are there for them and understand about their health and sexual health. As an up and coming nurse, I feel that understanding of a hospices patient’s sexual health is a very important component of their everyday life. I hope to one day use all of the information that I have acquired to help someone progress through their life with a since of recognition and aspiration. To know that I changed someone’s life even at the end, gives me satisfaction as a nurse that I didn’t just help a patient but a human being. In my scope of practice, I want to be knowledgeable and caring when the circumstances show their selves.


Marianne Matzo PhD, GNP-BC, FAAN. Kamal Hijjazi PhD, RN. (2009). If You Don’t Ask Me…Don’t Expect Me to Tell: A Pilot Study of the Sexual Health of Hospice Patients. Journal of Hospice and Palliative Nursing. 11(5), 271-281

Free Essays

Schizotypy & Creativity: Schizotypy and mental health amongst poets visual artists, and mathematics.


There has always been a notion that there has to be a connection between creativity and the predisposition to mental illness.

This article in particular Daniel Nettle categorises the element of mental illness into numerous schizotypal traits of people who suffer from serious psychopathology, by a series of studies and the use of an O-LIFE inventory, Nettle investigates into the different domains of creativity with the use of a sample consisting of mathematicians, artists, poets, psychiatric patients and the general population, within these studies he concentrates on the similarities and differentiating factors of those who are considered healthy creative’s, who hold schizotypal traits and psychopathology.

It was discovered that poets and artists have a higher level of unusual experiences than general population which coincidently coincide with those who have schizophrenia, other articles support the similarities between creativity and schizophrenia in particular (Kirton 1989)identifies that the ability to produce new ideas and adapt, improve, or create new functions for existing products defines creativity although these are skills that are impaired in majority of patients with schizophrenia, Nettle’ however made an identification that the defining difference between the two was the negative aspect of introvertive anhedonia which was present with psychiatric patients, however poets and artists had a relatively low dimension of this.

Elements of creativity consists of different domains within a specialist subject, because there are many sections of the brain required to control the element of thinking, schizophrenia, affective disorder and mathematics is an example of convergent thinking and autism to which introvertive ahedonia is a revealing characteristic.

The first of the series of studies revealed was based upon biographical and survey studies that identified high levels of psychopathology, particularly depression and bipolar disorder which was established as a commodity among individuals immersed in the fields of literature and the arts this supported the notion that there is a link. (Andreasen, 1987; Andresen & Carter, 1974; Jameson, 1989, 1993; Ludwig 1995; Post, 1994)

The secondary studies however were family studies, which unveiled relations into creative traits and aptitudes of close relatives of psychiatric patients excluding the confounding variable of proximity as it included those that had been separated by adoption. Fisher et al (2004) agrees as he suggested creativity may be genetically mediated. A study in support of this found that, a number of female writers, displayed creativity and a range of mental illnesses, which were also apparent in their close relatives (Ludwig, 1994). These studies conducted between the time of (1966 Heston, 1988 Kinney and Lunde) were suggestive of the idea that personality and cognitive traits are hereditary which interlinks the effects of mental illness and creativity. Geofrey F Miller, I.R tal article investigated into the extent to which schizophrenia and aspects of schizotypy was hereditary especially in terms of positive side effects such as divergent thinking and creativity, this article questions the possibility as to whether psychoticism can filter throughout genes and develop into other characteristics. Within this article in particular it argues that the creativity link is mediated by the personality traits openness and creativity and intelligence. Although in standard creativity models self reported family history of schizophrenia spectrum disorders did not predict creativity.

The third types of studies investigated into psychiatric patients diagnosed with schizophrenia and the comparison of their performance in alternate uses tasks that access divergent thinking with controls, it was discovered schizophrenia patients scored much higher. Neuropsychological evidence brought together by (Jocelyn et al 2004) finds evidence is in support of Nettles discovery, with schizotypy being a pronness to schizophrenia , it is not surprising that it is a commodity within research that positive schizotypy is related to patterns of cognitive and emotional function (divergent thinking ) which is a strong factor associated with both creativity and psychopathology.

In the next couple of studies, the fourth one like the third accessed the performances of creativity among the general population however this was against a scale designed to assess correlation as an indication of that particular individual’s liability to psychopathology.The final approach was basically a psychometric assessment of those in creative pursuits (Barron 1969; Eysenck 1993), though the outcome of these results were not as straight forward because they failed to identify a direct relationship, based upon the psychometric test used to identify personality traits, creative individuals showed very similar high levels in traits like neuroticism and openness to experience.

The O-life gives adequate psychometric properties in general population. Although, scales have not been tested for criterion validity against groups diagnosed with relevant psychopathology. (Jackson 1997) argues many high scorers of unusual experiences, do not suffer from psychopathology.A study by Gallup (1989, cited in Gallup & Newport, 2006) found that 43% of Americans and 33% of British had encountered unusual experiences, some a result of religion, suggesting more normality than psychopathology. This establishes an invalidation as unusual experiences are not has no direct correlation with psychopathology nor does it suggest mental illness which is evident from the Gallup study.

D. Nettles article repeatedly argues however more specifically that positive schizotypy is considered to be closely linked further to artistic creativity as opposed to scientific, throughout corresponding articles; it has been a common factor to find that scientific creativity has been more strongly associated with negative attributes such as intovertion or autism.

Literature suggests relationships between scizoptypy and creativity is an inverted U with both attributes increasing together, however as psychopathology begins to take its toll creativity lapses and begins to decrease (Akisktal, Akisktal and Richards et al 1988) this result was contradicted because mentioned earlier within the article research states schizophrenic patients had an enhanced performance on divergent thinking. Ludwig (1995) found that although those with creative brilliance did suffer from more psychological disturbances, symptoms were not serious enough to be considered abnormal. In support of the counter argument (Frank Barron 1972) drew to the conclusion that successful creativity is a combination of psychopathology and ego alleging it is the ability to cope with stress that is the determinant as to whether the outcome leads to the onset of damaging symptoms such as introvertive ahedonia and debilitating psychopathology or creative output.

Fisher, E.J article addressed the debate from a neuropsychological prospective and proposed the link between mental illness and creativity is likely due to common cognitive features involving the right hemisphere of the brain. Although Nettle considers evidence from previous studies, he fails to consider neuropsychological factors that link creativity and mental illness.

The fact that aspects defining creativity are all considered existent impaired factors that are immanent within schizophrenic patients, cannot deter the obvious link; however that is only in reference to one diagnosed mental disease that being schizophrenia, in terms of generalising to the terminologies psychosis and psychopathology that has yet to be debated. As much as evidence highlighted in this article supported the notion of the links between the ideology of creativity and mental illness, revelation into the questioning of reliability of certain methods of testing may need to be addressed such as the inconsistency of subjects per group; a significantly higher number of poets and visual artists than mathematicians and the participants talents were based upon self report forms which can be considered ambiguous, especially when participants had to differentiate between ‘professional’ or ‘seriously involved’ making it difficult to establish the participants true level.

Nettle recognises the association between creativity and mental illness and demonstrates strong arguments, initiating the likes of Rawlings & Locarnini and Miller to use Nettle as a foundation for their research, so Nettles contribution is undeniable as it was pioneering for further research to be conducted.


Fisher. al (2004) Neuropsychological evidence for dimensional scizoptypy: Implications for creativity and psychopathology. Journal of Research in Personality, 38, 24-31

Gallup, A. M & Newport, F. (2006). The Gallup Poll: Public Opinion 2004. Rowman & Littlefield Publishers, Inc. USA.

Miller. F.G (2007) Schizotypy versus openness and intelligence as predictors of creativity. Schizophrenia Research, 93, 317-324

Nettle, D. (2005). Schizotypy and mental health amongst poets, visual artists, and

mathematicians. Journal of Research in Personality, 40, 876-90

Rawlings. D, Locarnini. A (2007) Dimensional Schizoptypy , autism, and unusual word associations in artists and scientists. Journal of research in Personality, 42, 465-471

Free Essays

Primary Health Care


Primary health care is the first care which is mainly provided by GP practices, dentalpractices,community pharmacies and spec saveropticians. 90% peoplecontactwith primary care services. Primary health care providers refer the patientsto secondary care services which needs special medical care.

Secondary care service provided by medical specialists who generally don’t have first contact with patients, care is mainly provided by hospitals and clinics.

Tertiary care refers to those services which are highly technical and special services mostly provided by private medical professionals. It includes intensive care units and advanced diagnostic support services.

Aspect of discussion


I would like to discuss on the most common disease that is diabetes mellitus which is one of the fastest growing disease in this era. It is a complex metabolic disorder in which a person has high blood sugar. It may be resulting from defects in insulin secretions or insulin action. In this condition blood has a high level of glucose because body cannot use it in right way. Pancreas produces certain types of hormones and enzymes which helps to digest food and regulates blood glucose. These are produced by tiny cells known as islet on Langerhans. Most of the cells are beta cells which produce and store insulin. Also locate the alpha cells which produce and store glycogen. Glycogen counteracts the effect of insulin. After taking a meal carbohydrates in the meal converted into the glucose in the intestine and in liver and then enter the blood stream. After that beta cells sense the glucose level in the blood stream and secrete insulin. But because of any dis-functioning when pancreas does not produce any insulin and allows glucose to enter the body cells is called diabetes. It may be hereditary or mostly occurs in over 40 age-group people.

Figure 1

The normal level of glucose in our body is:

CategoryMinimum levelMaximum level


Type 1 occurs when body fails to produce insulin and the person needs to inject insulin it is called insulin dependent diabetes mellitus.

In type 2 cell fails to use insulin properly it is called non-insulin dependent diabetes mellitus.

Gestational diabetes occurs in pregnant women, in this type blood glucose level become high during pregnancy then it may lead to development of type 2 diabetes.


Both types have similar signs

1. Polyuria

2. Polydipsia

3. Polyphagia

4. Fatigue

5. Blurred vision

6. Feeling of numbness

7. Dry itchy skin

8. Slow healing of cuts and wounds

9. Genital itching


Worldwide many people suffer from diabetes. 2.8% population has this disease its number increases rapidly. InUKnumber of people diagnosed has increased by more than 150,000.The data from GP practices shows that one in twenty of population is treated for diabetes and one in ten for obesity which is the main reason of diabetes.

InLuton9,000 peoples registered with GP who have diabetes. In this 4.3% are men and 5.0% are women and it is estimated that 350 new cases are found every year related to diabetes.


1. Heart disease and stroke

2. Nerve damage

3. Retinopathy

4. Kidney disease

5. Joint pain

6. Foot problems

7. Hypoglycemia

8. Visual impairment

9. Sexual dysfunction

10. Miscarriage and stillbirth

11. Amputation


Self-care is essential.
Always eat notorious food.
Take regular exercise.
Regular check -up of urine for albumin is important to manage diabetes.
Weight management programs for adults and children
Keep your weight under control
Never smoke.
Take medicine at time and if there is need to check sugar then learn how to check.
Take sugar free diet which is available.
By taking these minor things in mind one can control diabetes.


Screen tests are vital for diabetic complications i.e. foot examinations, retinopathy screening, and retinopathy symptoms. Good balanced diet is also helpful. Physical activities should be increased, keep your diabetes under control, eyes, feet, skin, teeth and gums should be keep healthy


Type1 of diabetes is always treated with insulin injections.
Type2 mainly requires healthy balanced diet, good exercise, physical activities to lose weight, some people need medication or insulin injection to get normal glucose level. Insulin can be given in different ways. It is of six types. Health care team decided which type is effective for a patient. Insulin is given via an injection,

by use of a syringe, pen device or by using an insulin pump. Mainly it is given under skin (subcutaneously) it may be administer in the stomach, thighs and inupper arms. When insulin is injected it is absorbed by blood vessels, then reaches in the bloodstream. Some medicines are also used to control glucose level. The best treatment is to adopt healthy lifestyle and early detection of disease.

In my area people are served in easy ways nurse is the first who would know the history of patient. There are some other resources for diabetic patients:

1. Support groups

2. Supporting membership

3. Care line and advocacy

4. Languages Centre

5. Insurance

These services offer advice, provide support, information, care events, latest research news and share experiences with group of diabetic patients as well as to their friends and family members.

It is very easy, first patient comes to GP when he recognizes the symptom of diabetes. They ask the patient about his family history, signs of experience etc. Then they will take urine and blood sample. They check it for glucose level; if urine contains glucose then blood test for glucose is essential. Fasting blood sample is most reliable to check diabetes. Oral glucose tolerance test is also available for the patients whose blood glucose level is not high enough for GP to diagnose diabetes.

Urine test for glucose level is simple and takes few minutes, on the other hands in FBS cases the patient has to go GP earlier with empty stomach but in OGT test the patient have to wait for some hours because they have drink a glucose drink after that in every half an hour or two hours blood tests are taken for testing how the body is reacting with glucose. In this type of test the patient have to wait for some hours but this type of test is taken in rare cases.

As everybody knows that diabetes is not a cure able disease, it can be controlled by medication or by injecting insulin. The patient who is receiving the care should know the clinical qualities to improve the health by taking the preventive, diagnostic, therapeutic and rehabilitative measures like eat healthy food.

Take regular exercise to reduce body weight, should not smoke because it induces vasoconstriction, and take regular treatment and checkup to control glucose level people with diabetic have to follow guidelines and clinical care. These are designed to access self-education and management, It is the only nurse who comes to contact with patient. She makes good interpersonal relationship with him. She advices the patient

about meal plan and explain procedures of insulin

for self- injection. She tells him to eat carbohydrate diet before exercise. She taught to assess feet, hands, soft tissue injuries, dryness of skin so the patient can identify the symptoms. Every nurse should have through knowledge and good experience to satisfy the patient. The evidence based knowledge tells NHS all knowledge and direct experience which they have to consult.

InLuton, most of people are Asian and Europeans. They have mostly this kind of disease; they did not know well English so in this area there are multilingual nurses who help health care services in identifying diabetic patients. She speaks with them in their own language and detects their problems. This is also helpful

to educating people about sign and symptoms, causes, treatment, prevention, facilities given and to supporting. She told them if they have related signs she took a finger prick it is early detection to identify diabetes. Then she reports to nearby GP and patient get treated in best way.


It is clear that the care provisions to diabetic patients are excellent and fit for its purpose. Nursing interventions are good and helps the local people to maintain their health. Patients of this disease get accurate treatment and well supported by care providers. If patients follow right instructions then they are able to get control on this disease. It is not one sided work in this both patients and care centers co-ordination is necessary. An experienced and qualified nurse is always required for excellence service provision because sometimes patients are diagnosed wrongly. The main care is started from GP and its provision is fit for patient care which is its main purpose.


1) ABC of Diabetes, First edition 2002 (Author “Peter.J.Watkins” )

2) Care of people with Diabetes- A manual of nursing practice, Edition 2009 (Auther “Trisha Danning ).


4) Figure 1:-

Free Essays

a major health issue and is often recognised as one of the major causes of avoidable mortality and morbidity in Western society

1. Introduction

Alcohol consumption is acknowledged worldwide as a major health issue and is often recognised as one of the major causes of avoidable mortality and morbidity in Western society (Wechsler, Dowdall, Davenport, & Castillo, 1995). Almost 4% of all deaths are attributed to alcohol (World Health Organization, 2009) and in relation to other causes of death, alcohol can be considered as a significantly higher contributor. For example, HIV/AIDS accounted for 3.5% of deaths worldwide, violence for 1% and tuberculosis for 2.5% (World Health Organization, 2004). This is reflected in increased cost for health care systems. In 2008, it was estimated that alcohol harm cost the National Health Service in England ?2.7 billion, this was a significant increase from estimates for 2003 of ?1.7 billion (National Health Service, 2010).

The harmful effects of high alcohol intake have been well documented (Hingson, Heeren, Winter, & Wechsler, 2005) (Schulenberg, Wadsworth, O’Malley, Bachman, & Johnston, 1996). Individuals who drink too much can suffer from physical problems, such as liver cirrhosis, heart failure and certain cancers, but also from social issues, such as interpersonal violence, sexual assault, vandalism, and driving accidents (Anderson & Baumberg, 2006) (Rehm, Room, Graham, Monteiro, Gmel, & Sempos, 2003). Definitions of alcohol abuse have also focused on social issues related to drinking; the Diagnostic and Statistical manual of Mental disorders (American Psychiatric Association, 2000) defines abuse as “a maladaptive pattern of substance use leading to clinically significant impairment or distress, often manifested as a failure to fulfil obligations, use in physically hazardous situations and related legal, social or interpersonal problems”.

The Government recommends that adult men should not regularly drink more than 3-4 units of alcohol per day and adult women should not regularly drink more than 2-3 units a day. However, in Great Britain, 31% of men and 20% women drink more than the advised weekly limits. Furthermore, 8% of men and 2% of women drink above the levels regarded as harmful, namely 50 units a week for men and 35 units for women (Office of National Statistics, 2008).

Age is an important variable contributing to alcohol consumption, with the highest intake recorded in young adults (Nolen-Hoeksema, 2004) particularly in those between 18 and 20 years old (May, 1992) (Webb, Ashton, Kelly, & Kamali, 1996). Drinking as a young adult has significant health consequences (Ham & Hope, 2003). The prevalence of drinking amongst young people does not only pose serious issues to the young people involved, but the consequences of their drinking can also have an effect on a their family and society as a whole (Oei & Morawska, 2004).

Alcohol consumption is a significantly greater problem within the student population because alcohol forms part of the university culture (Crundall, 1995). Drunken behaviour is accepted as normal at many student events (Davey & Clark, 1991). It has been found that alcohol is the most likely substance to be abused amongst the student population (Prendergast, 1994) and in comparison to non-university peers worldwide, students engage in riskier alcohol-related behaviour (Johnston, O’Malley, & Bachman, 2001) (O’Malley & Johnston, 2002) (Wiki, Kuntsche, & Gmel, 2010) (Kypri, Cronin, & Wright, 2005), drink more heavily (Kypri, Cronin, & Wright, 2005) (Dawson, Grant, Stinson, & Chou, 2004) and exhibit more clinically significant alcohol-related problems (Slutske, 2005).

It has been recorded that student consumption of alcohol is consistent with the rates of the general population in the UK, which is estimated to include 90% of adults consuming alcohol weekly (Department of Health, 2003). However, the amount of alcohol that is consumed by students has been suggested to pose significant risks.

Sociability has been identified as the major benefit to alcohol use. Specifically young people indicated that the reasons why they drink are for fun, to be happy, to gain confidence, to be cool and simply for something to do (Oei & Morawska, 2004). However, for students, hangovers were featured as the most negative aspect of drinking large amounts rather than longer term risks (Crundall, 1995). The students are also aware of the negative impact alcohol can have on their studies and finances (Bewick, Mulhern, Barkham, Trusler, Hill, & Stiles, 2008).

In America, one third of students were classified as suffering from alcohol abuse according to the DSM-IV-TR definition (as stated above) (Clements, 1999) and 6% reported symptoms of alcohol dependence (Knight, Wechsler, Kuo, Seibring, Weitzman, & Schuckit, 2002). Fewer than 4% of those students who met the DSM-IV-TR criteria for alcohol abuse or dependence were found to be willingly to pursue treatment (Clements, 1999) (O’Hare, 1997). Within the United Kingdom, a review of studies measuring undergraduate drinking concluded that 52% of men and 43% of women reported drinking above the recommended limits (Gill, 2002). Webb, Ashton, Kelly, & Kamali (1996) also found that 15% of a UK student sample drank at hazardous levels. For men this exceeded 51 units per week and 36 units for women.

Increased alcohol consumption and binge drinking are not only related to health issues, but also could result in negative consequences for the individual, such as academic failure, unintended pregnancy, sexually transmitted diseases, property damage, and criminal consequences that jeopardize future job prospects (Berkowitz & Perkins, 1986) (Hingson, Heeran, Zakocs, Kopstein, & Wechsler, 2002) (Wechsler, Dowdall, Davenport, & Castillo, 1995).

Students do not only experience consequences of their own drinking but often experience consequences of others drinking (Rhodes, et al., 2009). In addition to harmful effects on the individual, there are second-hand consequences for fellow students, ranging from disrupted study and sleep, to physical and sexual assault (Donovan, Jessor, & Costa, 1993) (Hingson, Heeran, Zakocs, Kopstein, & Wechsler, 2002) (Perkins, 2002) making students more at risk of negative consequences from alcohol consumption.

The hazardous consequences of binge drinking felt by many students arise from the disabling effects of consuming a large amount of alcohol over a short period (Oei & Morawska, 2004). The National Institute on Alcohol Abuse and Alcoholism advisory council approved the following definition for binge drinking: “A ‘binge’ is a pattern of drinking alcohol that brings blood alcohol content to about 0.08 gram-per cent or above. For the typical adult, this pattern corresponds to consuming 5 or more drinks (male), or 4 or more drinks (female) in about 2 hours” (National Institute on Alcohol Abuse and Alcoholism, 2004). Adams, Barry, and Fleming (1996) identified that while the number of drinks consumed per occasion was an important risk factor for death from injury, but that frequency of consumption was not. Binge drinking students are more likely to suffer from negative consequences related to than non-bingers such as academic problems, engage in high risk sex, sustain injuries, overdose on alcohol and drive while intoxicated (Wechsler, Dowdall, Davenport, & Castillo, 1995) (Wechsler, Lee, Kuo, & Lee, 2000) (Wechsler, Kuo, Seibring, Nelson, & Lee, 2002) (Jennison, 2004) (Vik, Carrello, Tate, & Field, 2000). Despite negative alcohol effects, research suggests that a large proportion of students are placing themselves at risk by engaging in binge drinking.

There are notable gender differences in binge drinking, as women are more likely to initiate drinking when they feel angry or worthless and as an escape from their troubles. On the other hand, for men incentives are to gain peer approval or not to show fear (Oei & Morawska, 2004). In Europe, Kuntsche, Rehm, & Gmel (2004) concluded that men were more likely to binge drink and that peer pressure was one of the strongest influencing factors. Similar findings have been reported for UK undergraduates, (Wechsler, Dowdall, Davenport, & Rimm, 1995) recorded 50% of male students to be binge drinking (around 8 UK units per session) and 39% of women (?6.5 units) at least once in the preceding fortnight. Pickard et al (2000) also found that 50% of men binge drink. However, they found more women were likely to binge drinking (63%).

Research suggests that heavy drinking among students is most likely to occur in positive social contexts as opposed to negative contexts (Carey, 1995) (Carey, 1993). There are again gender differences in these consumption patterns. For example, University men tend to drink more often than their female peers in positive situations, such as those involving cues to drink and pleasant times with friends (Carrigan, Samoluk, & Stewart, 1998). Other findings suggest that social contexts can discriminate between heavier and lighter male student drinkers, whereas the strongest predictor of discrimination between heavier and lighter drinking university women is emotional pain (Thombs, Beck, & Mahoney, 1995). Such gender differences suggest that drinking behaviour may be motivated by different subjective beliefs regarding the consequences of alcohol consumption for men and women.

The beliefs people hold about the effects of consuming alcohol are referred to as alcohol outcome expectancies (AOE) (Goldman, Del Boca, & Darkes, 1999) and include areas such as assertion, affective change and tension reduction (Young, Connor, Ricciardelli, & Saunders, 2006). According to social-learning theory, drinking is a goal-directed behaviour that ranges from abstinence to alcohol dependence, and the initiation, maintenance, and development of drinking patterns is assumed to be directed by similar learning principles (Abrams & Niaura, 1987) (Bandura, 1969) (Jones, Corbin, & Fromme, 2001) (Maisto, Carey, & Bradizza, 1999).

Within this theoretical framework, alcohol outcome expectancies are considered to be critical determinants of different consumption patterns and a result of indirect and direct drinking experiences. These beliefs are particularly important when experiences with alcohol are less developed. For instance, young children’s expectancies of alcohol are best described as indeterminate and diffuse and their beliefs “crystallize” with age (Miller, Smith, & Goldman, 1990). These expectancies influence not only present behaviour, but also the perceptions of later experiences with alcohol, which may strengthen the original expectancies (Oei & Morawska, 2004).

AOE have been shown to be better predictors of various drinking patterns that demographics and background variables (Brown, 1985) (Christiansen & Goldman, 1983). Expectancies have consistently been found to be associated with current alcohol consumption in students (Leigh & Stacy, 1993), community samples (Brown, Goldman, Inn, & Anderson, 1980) and adolescents (Christiansen, Smith, Roehling, & Goldman, 1989). Expectancies were found to predict future drinking in adolescents after 1 year (Christiansen, Smith, Roehling, & Goldman, 1989), 2 years (Smith, Goldman, Greenbaum, & Christiansen, 1995) and 9 years (Stacy, Newcomb, & Bentler, 1991).

Research has shown that individuals with positive alcohol expectancies drink more alcohol and are at risk of misusing alcohol (Connor, Young, Williams, & Ricciardelli, 2000) (Young & Oei, 1996). Other research has provided evidence that expectancies partially mediate other variables (e.g. temperament, alcohol knowledge, etc.) that influence alcohol consumption (Smith, Goldman, Greenbaum, & Christiansen, 1995) (Kline, 1996) (Scheier & Botvin, 1997), the extent to which other variables influence drinking through expectancy ranges between 17% and 50% (Greenbaum, Brown, & Friedman, 1995).

The belief about alcohol’s power to change behaviour, rather than its true physical effects determine the behavioural effects of alcohol (Leigh, 1989) and also expectancies concerning the use of may operate differently in different social situations (Bot, Engels, & Knibbe, 2005).

Lee, Greely, and Oei (1999) found that drinking was related not only to positive expectancies, but also to negative expectancies regarding its effects and it is now well established that people hold both positive and negative alcohol-related expectancies (Fromme, Stroot, & Kaplan, 1993) (Leigh & Stacy, 1993) (Chen, Grube, & Madden, 1994) (McMahon, Jones, & O’Donnell, 1994).

Positive alcohol outcome expectancies refer to peoples’ motives for drinking and their perceptions of the positive outcomes associated with drinking alcohol. They have been shown to be causally related to alcohol consumption in both adults and adolescents (Christiansen, Smith, Roehling, & Goldman, 1989) (Dunn & Goldman, 1998) (Smith, Goldman, Greenbaum, & Christiansen, 1995) and also to problem drinking (Lewis & O’Neil, 2000). Negative expectancies refer to peoples’ motives to abstain from drinking alcohol or to limit consumption. Earleywine (1995) found that only positive, not negative, expectancies were related to intentions to drink and drinking behaviour. However, Werner (1993) found both positive and negative outcome expectancies and their subjective evaluations accounted for a significant portion of the variability in drinking patterns and health problems reported by students. Further support has been found, using a variety of different instruments, that negative expectancies significantly improve the ability to predict current drinking (Fromme, Stroot, & Kaplan, 1993) (Leigh & Stacy, 1993) (McMahon, Jones, & O’Donnell, 1994). These inconsistent findings might be attributable to different explanations of negative expectancies. For example, Leigh (1989) suggested that expectancies can separated into short-term, direct effects and longer-term negative effects of drinking. The comparison between positive and negative expectancies is also confounded by the fact that the expected positive effects are more proximal than the expected negative effects. For example, positive expectations, such as feeling more sociable, happen at the time of drinking compared to negative expectations (such as hangovers) which happen as a consequence of drinking. These expectancies follow the pattern of actual alcohol effects (Earleywine & Martin, 1993).

While the vast majority of research has focused on participants’ expectancies for the effect alcohol has on themselves, the alcohol-related expectancies that a person has for others have been shown to influence drinking behaviour as well (Borjesson & Dunn, 2001). Participants consistently expected alcohol to affect other people more than themselves for both positive effects (such as social or sexual enjoyment) and negative effects, such as impairment. However, moderate and heavy drinkers expected as much social/physical pleasure from alcohol as they expected others to receive (Rohsenow, 1983). Men expected themselves to become calmer and happier in comparison to others when drinking, but also that others would become more disinhibited and to generally misbehave compared to themselves (Gustafson, 1989). Sher, Walitzer, Wood, & Brent (1991) found that men reported significantly stronger outcome expectancies than women for social lubrication, activity enhancement, and performance enhancement in other women. These findings were replicated with a separate sample of men and women in a subsequent longitudinal study (Sher, Wood, Wood, & Raskin, 1996).

This study is aimed to investigate the relationship between participants AOEs and those they hold for their friends further in a student population. It is, also, aimed to investigate the relationship between AOEs and alcohol consumption.

The Alcohol Use Disorders Identification Test (AUDIT) is a simple ten-question test developed by the World Health Organization as a simple method of screening for excessive drinking. The first edition of this manual was published in 1989 and was subsequently updated in 1992. Questions 1 to 3 concern alcohol consumption, 4 to 6 relate to alcohol dependence and 7 to 10 consider alcohol related problems. A score of more than 8 for men or more than 7 for women indicates a strong likelihood of hazardous alcohol consumption and a score of 20 or more is suggestive of alcohol dependence.

Alcohol outcome expectancies were measured using the Comprehensive Effects of Alcohol Questionnaire (CEOA) (Fromme & Stroot, 1993). This questionnaire assesses both positive and negative discrete expectancies of alcohol’s effects on physiological, psychological, and behavioural outcomes. Participants rated 38 items on a four-point Likert scale ranging from “disagree” (1) to “agree” (4) based on their expectation of the likelihood that the outcome will occur whilst they are drinking alcohol. Expectancies are divided into subscales, four of which address positive outcomes (Sociability, Tension Reduction, Courage, and Sexuality) and three addressing negative outcomes (Cognitive and Behavioural Impairment, Risk and Aggression, and Self-Perception). Examples of positive outcome expectancy items include: “I would feel energetic” or “I would feel unafraid”. Examples of negative outcome expectancy items include: “I would be clumsy;” “I would take risks” or “I would feel guilty”.

Scores for expected outcomes are determined by summing relevant subscale responses, allowing two overall scores to be calculated for each participant: positive expectations, negative expectations, and a total score for all expectations. The CEOA was found to have adequate internal consistency and temporal stability, and criterion and construct validity in a student sample (Fromme & Stroot, 1993).

For the purpose of the present experiment, individual alcohol outcome expectancies were assessed using the standard CEOA questionnaire, additionally, participants were asked to respond to CEOA items on the basis of answering for a chosen friend. Examples of friend’s outcome expectancy items included: “They would act sociably” or “Their senses would be dulled“.

This study found no significant differences in gender in AUDIT scores. Therefore the null hypothesis can be accepted. With regards to gender and alcohol consumption, findings from this study found only slight but non-significant differences between the consumption of men and women, with women drinking only slightly more than men. Although similar results were found in the study by (Labrie, Migliuri, Kenney, & Lac, 2010), their study was focused on participants with a family history of excessive alcohol consumption. It was only within participants with a family history of excessive alcohol consumption that gender differences were found. The findings in the present study were inconsistent with the findings of (Prendergast, 1994) who found it more likely for men to abuse alcohol than women. However, this study was a review of previous literature (1980 to 1994) and more recent research evidence would suggest that gender differences are decreasing (Keyesa, Grantic, & Hasin, 2007). In addition, this study used an American sample and findings may not be applicable to those in the UK. This suggests that women are at greater risk of alcohol disorders, with 6.4% of men compared to 11.3% of women identified as being dependent on alcohol according to AUDIT score.

In comparison to the general population men in this study were less likely to be classed as drinking above hazardous levels (8% vs. 6.4%) whereas many more women were drinking at these levels (2% vs. 11.3%) (Office of National Statistics, 2008). This suggests that the population used in this study is not representative of the general population in regards to dependent levels of drinking which could result in unique findings.

Participant’s alcohol expectations were found to significantly affect AUDIT score and therefore we can reject the null hypothesis. This is similar to the results of (Leigh & Stacy, 1993). It was also found that positive and negative outcome expectancies accounted for a significant portion of the variability in drinking patterns, similarly to other previous research (Werner, Walker, & Greene, 1993). As with previous research, it has been found that increased positive AOEs relate to higher consumption. Alternatively, in this sample, negative AOEs also appear to be related to increased alcohol consumption. It has been suggested that positive expectancies are immediately accessible and therefore contribute to initiation of alcohol use. Whereas, negative expectancies are delayed and shaped by subsequent drinking, therefore their influence may be related to persistent drinking (Sher, Wood, Wood, & Raskin, 1996) (Bauman, Fisher, Bryan, & Chenoweth, 1985) (Kuntsche, Knibbe, Engels, & Gmel, 2007). In this study, participants were drawing on memories of drinking experience to shape their expectancies. This could have allowed them to evaluate AOEs equally, with proximal and distal effects playing a less important role. The findings underscore the importance of attitudes and strength of beliefs, particularly in identifying those at high risk for problem drinking and adverse health consequences.

A multiple regression indicated that a person’s AOEs for the Risk and Aggression subscale are a significant predictor of AUDIT score and also expectancies explained 21.6% of the variance in scores. This appears consistent with the findings of Fromme and D’Amico (2000) who found AOEs explained 28% of the variance in quantity of alcohol consumed, and 15% of the variance in frequency of drinking. Ham, Stewart, Norton, & Hope (2005) found the Risk and Aggression subscale of AOEs to be related to alcohol consumption in adolescents, specifically drinks per week. However, they found this was not the only subscale related to alcohol consumption but also an association was found with Liquid Courage, Sociability and Sexuality expectations. Alcohol consumptions relationship with expectancies seems to be especially true for the expectancies of both physical and social pleasure, relaxation and tension reduction and possibly enhanced sexual functioning (Gustafson, 1989). This suggests that the relationship between expectancies and AUDIT score is mediated by the population being studied and what is specifically been measured. Due to different measures of expectancies it is difficult to compare results directly. Measurements can relate to a range of expectancies; from general expectancies to specific expectancies. This is also true for measures of alcohol consumption. The AUDIT does not only address participant’s consumption but also alcohol dependence and alcohol related problems. It is also possible that some drinkers use expectancies as a justification for drinking, rather than solely associated with drinking. Gustafson (1989) found a positive correlation between the strength of expectancies and how desirable it was rated as an outcome of drinking. Therefore people could be drinking to achieve expectations rather than expecting certain consequences of drinking.

A logistic regression indicated that the Sexuality, Risk and Aggression, and Self-Perception subscales reliably predicted using alcohol at risky levels. Expectancies explained between 22.3% and 32% of the variance in risk classification, and 83% of the predictions were correct. Ham, Stewart, Norton, & Hope (2005) found that 44% of the variance in high level drinking to be attributed to AOEs. This higher level could be due to the sample population used in the study. For the current sample, there were no effects of AOEs on AUDIT score for men (see below), and therefore the variance in risk classification reflects upon women’s expectations for alcohol. Similarly this could explain why Ham, Stewart, Norton and Hope (2005) found that greater the expectancies for Self-Perception and Cognitive and Behavioural Impairment, the more likely participants were to have alcohol related problems, this was consistent with findings of Lee, Greely, & Oei (1999). Also Gustafson (1989) found that high consumers have stronger AOE and that all expectancies, bar Sexuality, were related to higher levels of alcohol consumption. These results suggest that certain expectancies are related to risky drinking, however, the expectancies that reliably predict risk is determined by the population that is being investigated. Further to this, some research has found that expectancies did not appear to be related to consumption in problem drinkers (Oei, Fergusson, & Lee, 1998) this suggest that further research needs to be conducted into the relationship between level of alcohol consumption and AOEs.

There was no effect of AOEs on AUDIT score for men. However, there was an effect for women, therefore we can reject the null hypothesis. This does not follow previous research as it has been found expectations that alcohol would improve social situations had the highest correlations with actual alcohol use in men. Men’ alcohol use corresponded to the belief that men in general have positive personality changes due to drinking, and that men drink to relieve social anxiety (Borjesson & Dunn, 2001). These findings appear inconsistent with research by (Brown, Goldman, Inn, & Anderson, 1980), who found that women expected more positive social consequences from drinking alcohol, whereas men were more likely to expect potentially aggressive behaviour and more negative expectations. This difference could be because of gender differences within the population used. Although the sample population is similar to the UK populations with more men than women (UK; 51% women, Study; 62% women) (Office of National Statistics, 2008), it is inconsistent with that of Loughborough University (62% men) (The Complete University Guide, 2011). The choice of women to attend a predominantly male University may have affected the results as University choice may be determined by personal characteristics and lifestyle choices.

There was a relationship between participants and friends AOEs, specifically for the same type of expectations (positive to positive and negative to negative), and therefore the null hypothesis can be rejected. A modified version of the CEOA was used to identify friend’s expectations and therefore its individual validity and reliability has not been tested. This means that the data can only be indicative of a relationship, but similar results have been found before (Rohsenow, 1983). Participants expected alcohol to affect other people more than themselves. However, this was more pronounced for negative effects. People typically drink more or less in response to the consumption rates of others in their drinking environment (Caudill & Marlatt, 1975) (Lied & Marlatt, 1979), especially when people are friendly (Collins, Parks, & Marlatt, 1985). The belief that others will experience more AOEs effects than themselves, a person’s own alcohol consumption could be effected. Individuals could be drinking more than to others because they underestimate the effect alcohol is having on themselves in regards to others. Research has identified social context and peer influence as risk factors for problematic student drinking (Ham & Hope, 2003). The current study is limited because it does not investigate the relationship of specific expectancy subscales. It has previously been found, however, that, others who consumed large amounts of alcohol were seen as more relaxed, less inhibited, more aggressive, and less attractive than those who drank none or little (Edgar & Knight, 1994). And those who themselves drank less were more likely to expect others to become more aggressive and relaxed than their moderate or heavy drinking counterparts (Rohsenow, 1983).

When looking at different levels of alcohol consumption, it was found that there was no relationship between participants and friends expectations for those not drinking at risky levels. For those classified as hazardous drinkers there was only a relationship between the same type of expectancies (positive and positive, negative and negative). In opposition to this there was a relationship between opposite expectations for those classified as dependent drinkers. Therefore the null hypothesis can be rejected. Alcohol expectancies have been shown to correlate with all levels of drinking (Goldman, 1999). The lack of defining an specific amount of alcohol in this study, instead specifying to base assumptions on a friend consuming the same amount as the participant, could have affected the results. Therefore those drinking low levels of alcohol are also rating their friends drinking low levels which may not be representative of normal drinking. Those drinking at dependent levels may have been more aware of drinking large amounts because they had previously completed the AUDIT. Specifically those drinking at dependent levels expected that their friends would have more negative expectations than themselves. Students are suggested to be aware of the negative consequences of drinking (Bewick, Mulhern, Barkham, Trusler, Hill, & Stiles, 2008), but choose to ignore them in relation to their own drinking. More research needs to be conducted into the relationship between this relationship, specifically in respect to reducing high drinking levels by making people fully aware of the negative effects of drinking.

There was no overall significant effects of men expectations for their self and friends expectations, however there was an effect of positive AOEs on friends positive AOEs. For women there was an effect of total expectations on friends expectations, specifically participants own negative AOEs and friends negative AOEs. Therefore the null hypothesis can be rejected. Expectancies of alcohol use are theorised to develop through learning from repeated experience with alcohol, either personally or observed. Therefore, an individual’s own perception of the consequences of drinking becomes an important factor in the associations (Bauman, Fisher, Bryan, & Chenoweth, 1985) (Jones & McMahon, 1992). In most cultures and societies, one of the most secure observations is that consequences surrounding consumption are tolerated more in men than in women (McMahon, Jones, & O’Donnell, 1994). This suggests that alcohol behaviours would generally be judged more by the individual if they were female than if they were male. These differences could be due to the population being sampled with women being less influenced by the way alcohol behaviour is perceived. Also it has been observed that women in the population score higher on the AUDIT than men, contrary to that of the general population.

It is important that future research takes into account other variables that affect the relationship between alcohol use and AOEs. This can then be used to better understand of why so many people drink risky levels despite the knowledge that it can be harmful. Specifically it is suggested that the desirability of AOEs is an important factor in understanding the relationship of expectancies to drinking (Leigh, 1987).

2. Conclusion

The aim of this study was to investigate relationship between participants AOEs and those they hold for their friends in a student population. It was, also, aimed to investigate the relationship between AOEs and alcohol consumption. Participant’s AOEs were found to significantly affect AUDIT score (F(46,71) = 1.651, p < 0.005, partial ?? = 0.517). There was no effect of AOEs on AUDIT score for men(F(31,15) = 0.821, p = 0.690, partial ?? = 0.629). However, there was an effect for women (F(36,34) = 1.818, p < 0.05, partial ?? = 0.658). There was a relationship between participants and friends AOEs (F(46,71) = 3.009, p < 0.005, partial ?? = 0.661).

The findings of the present study are consistent with previous studies that have shown AOEs to be significant predictors of alcohol consumption (Fromme, Stroot, & Kaplan, 1993). This highlights the importance of investigating the effects of AOEs within specific populations, and how AOEs can be controlled to effect alcohol consumption.

Free Essays

Nursing health assessment is an important role for a patient being diagnosis and give appropriate treatment


Nursing health assessment is an important role for a patient being diagnosis and give appropriate treatment (Bellack, 1992, p.12). In my past clinical practice, only some simple assessments were conducted as it is able to reduce the affect of the problem but not solve it. After studied nursing health assessment, some more extensive and specific assessments should be done to identify patient’s health status. The actual problem, strengths deviations and the risk of the health problem are explored at a detail and in-depth way. This article is going to discuss about the specific nursing health assessment for a patient suffered from abdominal pain, who was met in my past practicum placement.

Case scenario

Ms. Ma, Age 54, housewife, admitted via A&E and complained she was having abdominal pain for 5 days. Sharp pain starts at mid-abdomen and then at right lower quadrant. Level of pain increased when coughing. She had had Panadol 500mg an hour ago but pain can not relief. Nausea and vomited small amount of undigested food twice in the past few days. No diarrhea. She feels tired but can not sleep because of the sharp pain. Her vital signs are: pulse 98, blood pressure 148/85 mmHg, temperature 39.2oC. Her skin is warm and dry. Rebound pain occurred at the right lower quadrant of abdomen. She has hypertension and need to take medicine 2 times per day.

Ms. Ma was diagnosed with acute appendicitis. Keep NPO and IV 500ml normal saline is established. Blood test, abdominal X-ray and ultrasound abdomen are planned.

Assessment of abdomen

In the past clinical practice, I only give analgesics by doctor’s order and the patient may sometimes relief pain after medication. However, abdominal assessment skills are necessary to identify Ms. Ma‘s condition for getting at the root and having a better outcome.

There are five important steps for evaluating abdomen: take health history, inspection, auscultation, percussion and palpation. These assessment skills will be discussed one by one in the following paragraphs.

Health history and lifestyle health practices

First, find out the patient’s chief complaint, record the details and observe Ms. Ma‘s general appearance.

Then, assess the abdomen pain by COLDSPA— character, onset, location, duration, severity, pattern and associated factors. It is the most accurate measurement to identify whether it is parietal peritoneal pain, visceral pain or referred pain (Judy, 2008).

After that, collect individual and family past and current health status. Ask if there was any injuries or trauma may cause the pain, any eating disorder, any abdominal surgery was done before, any food allergy, history of suffering inflammatory bowel disease, family history of cancer and chronic disease, etc. Also, collect Ms. Ma‘s lifestyle and health practices. Ask her if smoke, drink or not, her eating habit, bowel pattern and movement, the amount, colour and texture of stool, any change in appetite, weight and abdominal girth recently and her stress level (Medical Education, 1998).

Past history and current lifestyle health practices are the useful information to identify the risk factors of the problem.

After collecting all background information, the physical examination should be proceed. Physical examination is using senses to collect objective data. It is used to identify the actual and potential health problems, discover patient’s abnormalities and diagnosis the problem (Nursing 2010 Magazine, 2010).

For physical examination of abdomen, Ms. Ma needs to empty her bladder first in order to avoid the bladder irritation then, place Ms. Ma in a supine position. The hands should be at aside and knees slightly bent. Tell her keep relax of the abdominal muscles. The assessment should be started in the right lower quadrant of abdomen and then proceeding in a clockwise direction. Also, the examination should go forward in the order of inspection, auscultation, palpation and finally percussion for avoid affecting the quality of bowel sound and increase peristalsis (Bellack, 1992).

Physical examination of abdomen


Inspection is systemic visual examination. For abdominal examination, it should be started at the mouth, which is the beginning of gastrointestinal tract, and finally the rectum and anus (Bellack, 1992).

First, ask Ms. Ma opens her mouth and says “Ar” or use tongue depressor to inspect the structure of mouth cavity to see whether any inflection, ulcer or not. Then, give a swelling test to Ms. Ma for examine the swelling ability. Place a spoon with some water on the middle part of her tongue and ask her to swell the water slowly to observe any choking or water leaks out. After that, inspect the texture of abdomen, the condition and colour of skin, any bruises or scars presence on abdomen. Normally, abdomen is homogenous in colour. If redness or yellow orange appear, it may indicate inflammation or liver disease respectively. Normal abdomen should also be symmetry from side to toe, flat and have normal movement when smooth respiration. If the abdomen is asymmetric, obesity, abnormal enlargement of organs, fluid distention or even intestinal obstruction may be suffered. Also, aortic pulsation should be present as Ms. Ma is having hypertension. Finally, ask Ms. Ma to take a deep breathe and hold it, it is used to inspect the presence of hernias or not (Bellack, 1992).


Auscultation of abdomen is used to define the bowel sound, which are caused by the movement of air or fluid at small intestine, by stethoscope.

The examination is started at the right lower quadrant, where the clearest bowel sound can be heard. Normal bowel sounds are at high-pitched, bubbling sound and occur five to thirty times per minute. If hyperactive bowel sounds occur, it indicates diarrhea or early stage of gastroenteritis. If hypoactive or even absent of bowel sounds for five minutes, it indicates intestinal obstruction, peritonitis or pneumonia.

Besides bowel sounds, vascular sounds of aortic, renal, iliac, and femoral arteries can also be auscultated. It is an important examination to assess hypertension patient such like Ms. Ma whether she suffers from portal hypertensive and liver cirrhosis or not. If the vessels constricted or dilated, a bruit can be heard when blood flows (National Institute for Health and Clinical Excellence, 2008).


Palpation is using sense of touch to collect data. For abdominal examination, finding out the location of pain is a great help of diagnosis abdominal pain. Light palpation and deep palpation are used to assess the abdominal organs, to define the tenderness and presence of mass. It is essential to assess the liver and spleen in abdominal examination.

Light palpation which is not more than 1 am deep on each quadrant. Normal abdomen should be smooth and consistent. If broad-like hardness appears, it states peritoneal irritation is suffered.

Deep palpation, which is press deeply from5cmto8cm, is used to indicate the abdominal organs and detect some obscure masses. Palpate the liver to test Murphy’s sign of cholecystitis. Palpate on the right upper quadrant at midclavicular line and parallel to the midline. If Ms. Ma feels pain and has inspiratory arrest, it states positive Murphy’s sign and indicate cholecystitis. Then, palpate the spleen at costal margin on left upper quadrant to feel if the spleen is enlarged and Ms. Ma will feel pain when the peritoneum is inflamed.

Finally, as the rebound tenderness was being tested to Ms. Ma, that is pushing 90o angle at the right lower quadrant deeply and then release quickly. It is the reliable test of peritoneal inflammation if the patient feels sharp pain when the force released (Watkins, 2010).

Besides, obturator test and iliopsoas test can also be done for diagnosing appendicitis. For obturator test, Ms. MA need to hold her right leg above the knee at 90o angle, grasp the ankle and rotate her leg laterally and medically. If she feels pain, it states obturator muscle is irritated. For iliopsoas test, straight up Ms. Ma’s right leg and press deeply on her upper thigh and ask her to oppose the pressing force. If she feels pain, it states that she is suffering from appendicitis (Beltran, 2009).


Percussion collects data by vibrations and sounds. For abdominal examination, percussion is used to assess the amount of fluid or gas, the location of mass, the size of liver and spleen. Normally, tympanic sound is found at hollow organs such as stomach and intestine; dullness sound is found at liver, spleen or masses.

To estimate the liver is enlarged or not, the normal distance of liver is 6 to12cm, which depends on the body size and gender, at the midclaricular line.

To estimate the spleen by percussing behind the left midaxillary line. If the distance is greater than7cm, it states that the spleen is enlarged due to infection, mononucleosis or trauma.

Moreover, test of shifting dullness and fluid wave to assess ascites. If the ascites of abdomen is more than 500ml, shifting dullness will be found. Normally, tympany is produced at abdominal midline (Bellack, 1992). However, for the abnormal case, dull sound is produced because of the cumulated fluid. Ask Ms. Ma rolls to right side and percuss from top to bottom. If the fluid is present, sound will change from tympanis to dullness and fluid wave will be generate when percuss on a side of the abdomen. It also has great variate in the abdominal girth.


After the physical examination, documentation is necessary for the findings and development of care plan.

Current of illness

Ms. Ma states that her abdominal pain started five days ago. On the pain scale from 0 to 10, as 10 being the worst, she rates her pain is 7. Sharp pain occurs at mid-abdomen and then at right lower quadrant continuously. Level of pain increases when coughing. She has no known drug allergy and food allergy. She had Panadol 500mg an hour ago but pain can not relief. Nausea and vomited small amount of undigested food twice in the past few days. She has loss of appetite and lost about 3 pounds of body weight. No change in her abdominal girth. She has no diarrhea. She feels tired but can not sleep because of the sharp pain. She is having fever as her vital signs are: pulse 98, blood pressure 148/85 mmHg, temperature 39.2oC.

Past health history and lifestyle practice

Ms. Ma is a non-smoker and non-drinker. She has hypertension and need to take medicine 2 times per day. No abdominal surgery was dome before. She denies any injury or trauma occurs recently on her abdomen. She does not have history of suffering inflammatory bowel disease or family history of cancer and chronic disease.

She states that her eating habit is health and the amount, colour, texture of stool are normal, but constipation sometimes. She does not feel stress or depression.

Physical examination

Ms. Ma has normal structure of mouth cavity and good swelling ability. There is no bruise or scar presence on abdomen. Her abdomen is symmetric and homogenous in colour. Her skin is warm but dry. By using the stethoscope, her bowel sounds are normal and no bruits are heard. Ms. Ma has rebound tenderness at the right lower quadrant of abdomen, pain occurs at obturator test and iliopsoas test when palpation. Normal tympanic sound is produced at abdominal midline when percussion.

Action and responses

Ms. Ma is hospitalized. IMI 50mg Tramadol is given and her pain is temporary relief. Blood test was done and the result shows the level of white blood cell is high. The abdominal X-ray and ultrasound abdomen show her appendix is enlarged

Ms. Ma is booked for an urgent operation for appendectomy.


In conclusion, some early symptoms of disease are not obvious, which will be easily misdiagnosed. Therefore, collecting health history and physical examination are very important as the data collected are in-depth and specific. It helps to have fast and accurate diagnosis in order to provide appropriate treatments to solve the patient’s problem and the symptoms at the same time.


Bellack, J.P. (1992). Nursing assessment and diagnosis (2nd ed.).Boston : Jones andBartlett Publishers.

Beltran, M. (2009). Give this diagnostic test if appendicitis is suspected: early acute appendicitis may be difficult to diagnose. ED Nursing, 12 (5), 56-67.

Judy, B. (2008). Pain evaluation and assessment. London : Piper Books in association with Heinemann.

Medical Education. (1998). Nursing Assessment [Videotape].America: Meridian Education Corporation.

National Institute for Health and Clinical Excellence. (2008). Appendicitis [Brochure].England:Newcastle Health Information Centre.

Nursing 2010 Magazine. (2nd ed.). (2010).America: AuthorBio Publishing Group Ltd.

Watkins, J. (2010). Recognizing the signs of acute appendicitis. British Journal of School Nursing, 5 (10), 488-91.


Free Essays

The role of the nurse in health promotion


This assignment proposes to discuss the role of the nurse in health promotion. To facilitate the discussion in the delivery of primary, secondary and tertiary levels of health promotion, the health risk of tobacco smoking in relation to Lung Cancer has been chosen. National policies will be explored in relation to smoking and how these influence the delivery of health promotion by the nurse. The barriers to health promotion will be identified along with ways in which these may be overcome.

The intention of the World Health Organisation (WHO) to achieve “Health for All” by the year 2000 was published in their Ottawa Charter, the outcome of which was to build healthy public policy, create supportive environments, strengthen communities, develop personal skills and reorient health services. They identified key factors which can hinder or be conducive to health; political, economic, social, cultural, environmental, behavioural, and biological (WHO 1986).

The current health agenda for the UK aims to improve the health of the population and reduce inequalities with particular emphasis on prevention and targeting the number of people who smoke (DH 2010).

Inequalities in health have been extensively researched and although attempts have been made to overcome these, there is evidence to support that the divide between the rich and the poor still exists in society. Marmot (2010) highlighted the lower social classes had the poorest health and identified social factors such as low income and deprivation as the root causes which affect health and well being.Increased smoking levels were found to be more prevalent in this cohort. Bilton et al (2002) suggests the environment an individual lives in can have an adverse effect on health in that it can influence patterns of behaviour. For example, families living in poor housing conditions, in poverty or in an environment away from a social support network can suffer psychological stress; which in turn can prompt coping behaviours such as tobacco smoking (Blackburn 1991, Denny & Earle 2005).

Smoking is a modifiable risk factor to chronic disease such as Cancer of the Lung, with 90% of these cases being the result of smoking (Cancer Research UK 2009) itis the single biggest preventable cause of premature death and illness and is more detrimental to the poorer in society. Responsible for 80,000 lives per year, the huge financial burden on the NHS to treat illness associated with smoking is estimated at ?2.7 billion each year (DH 2010). This illustrates the huge opportunity for public health to address the wider issues associated with inequalities and to target people who smoke. Various White papers have demonstrated the Government’s commitment in reducing smoking figures and preventing uptake, both at individual and population levels, through health promotion activity, empowering individuals and enabling them to make healthier lifestyle choices (DH 2004, DH 2006, DH 2010).

Health promotion is a complex activity and is difficult to define. Davies and Macdowall (2006) describe health promotion as “any strategy or intervention that is designed to improve the health of individuals and its population”.However perhaps one of the most recognised definitions is that of the World Health Organisation’s who describes health promotion as “a process of enabling people to increase control over their health and its determinants, and thereby improve their health (WHO 1986).

If we look at this in relation to the nurse’s role in smoking cessation and giving advice to a patient, this can be seen as a positive concept in that with the availability of information together with support, the patient is then able to make an informed decision, thus creating empowerment and an element of self control. Bright (1997) supports this notion suggesting that empowerment is created when accurate information and knowledgeable advice is given, thus aiding the development of personal skills and self esteem.

A vital component of health promotion is health education which aims to change behaviour by providing people with the knowledge and skills they require to make healthier decisions and enable them to fulfil their potential.Healthy Lives Healthy People (2010) highlight the vital role nurses play in the delivery of health promotion with particular attention on prevention at primary and secondary levels.Nurses have a wealth of skills and knowledge and use this knowledge to empower people to make lifestyle changes and choices. This encourages people to take charge of their own health and to increase feelings of personal autonomy (Christensen 2006).Smoking is one of the biggest threats to public health, therefore nurses are in a prime position to help people to quit by offering encouragement, provide information and refer to smoking cessation services.

There are various approaches to health promotion, each approach has a different aim but all share the same desired goal, to promote good health and prevent or avoid ill health (Peate 2006). The medical approach contains three levels of prevention as highlighted by Naidoo and Wills (2000), primary, secondary and tertiary prevention.

Primary health promotion aims to reduce the exposure to the causes and risk factors of illness in order to prevent the onset of disease (Tones & Green 2004). In this respect it is the abstinence of smoking and preventing the uptake through health education and preventative measures. One such model of prevention is that of Tannahill’s (1990) which consists of three overlapping circles; health education for example a nurse may be involved in the distribution of leaflets educating individuals or a wider community regarding health risks of smoking, prevention, aimed at reducing the exposure to children, for example, in 2007 the legal age for tobacco sales increased from age 16 to 18 years in an attempt to reduce the availability to young people and prevent them from starting to smoke (DH 2008), health protection such as lobbying for a ban on smoking in public places.

If we look at this in relation to the role of the school nurse, this is a positive step when implementing school policies such as no smoking on school premises for staff and visitors, as this legislation supports the nurse’s role when providing information regarding the legal aspects of smoking.Research demonstrates that interventions are most effective when combined with strategies such as mass media and government legislation (Edwards 2010).Having an awareness of such campaigns and legislation is essential to aid best practice and the nurse must ensure that knowledge and skills are regularly updated, a standard set by the Nursing and Midwifery Council (NMC 2008).

Croghan & Voogd (2009) identify the school nurse’s role as essential in the health and well-being of children in preventing smoking. Many people begin to smoke as children, the earlier smoking is initiated, the harder the habit is to break (ASH) and this unhealthy behaviour can advance into adulthood.Current statistics illustrate that in 2009 6% of children aged 11-15 years were regular smokers (Office for National Statistics 2009). These figures demonstrate the importance of prevention and intervention at an early stage as identified by the National Service Framework (NSF) for Children, Young People and Maternity Services (DH 2004). Smith (2009) highlights the school nurse as being in an advantageous position to address issues such as smoking and suggests that by empowering children by providing support and advice, this will enable them to adopt healthy lifestyles.

NICE (2010) suggest school based interventions to prevent children smoking aimed at improving self esteem and resisting peer pressure, with information on the legal, economic and social aspects of smoking and the harmful effects to health.Walker et al (2006) argue self esteem is determined by childhood experiences and people with a low self esteem are more likely to conform to behaviours of other people.This can be a potential barrier in the successful delivery of health promotion at this level, with young children exposed to pressure to conform; they are more likely to take up unhealthy behaviours such as smoking (Parrott 2004).The nurse can overcome this by working in partnership with teachers and other staff members to promote self-esteem by ensuring an environment conducive to learning, free from disruptive behaviour which promotes autonomy, motivation, problem solving skills and encourages self-worth (NICE 2009).

Despite the well known health risks to tobacco smoking, unfortunately 1 in 5 individuals continue to smoke (DH 2010). Whitehead (2001) cited in Davies (2006) argues the nurse must recognise and understand health related behaviour in order to promote health. Therefore, when delivering health promotion the nurse needs to be aware of all the factors which can affect health, some of which can be beyond individual control. Smoking cessation is one of the most important steps a person can make to improve their health and increase life expectancy, as smokers live on average 8 years less than non smokers (Roddy & Ross 2007).

Secondary prevention intends to shorten episodes of illness and prevent the progression of ill health through early diagnosis and treatment (Naidoo & Wills 2000). This can be directed towards the role of the practice nurse in a Primary Care setting, where patients attend for treatment and advice that have symptoms of illness or disease as a result of smoking, such as Bronchitis. Nice guidelines (2006) recommend that all individuals who come into contact with health professionals should be advised to cease smoking, unless there are exceptional circumstances where this would not be appropriate, and for those who do not wish to stop, smoking status should be recorded and reviewed once a year. It is therefore essential the nurse maintains accurate and up to date record keeping.

Smoking cessation advice can be tailored to the specific individual and therefore it is important that the nurse has the knowledge and counselling skills for this to be effective. The process of any nursing intervention is ultimately assessment, planning, implementing and evaluating (Yura & Walsh 1978), this applies to all nurses in any given situation including health promotion. One such method of smoking cessation which can be used as an assessment tool is known as the 5 ‘A’s approach, ‘ask, assess, advise, assist, arrange’ (Britton 2004). “Ask” about tobacco use, for example how many cigarettes are smoked each day, and “assess” willingness and motivation to quit, taking a detailed history to assess addiction.Objective data can be obtained using a Smokerlyser which measures Carbon Monoxide levels in expired air (Wells & Lusignan 2003). These simple devices can be used as a motivational tool to encourage cessation and abstinence. Castledine (2007) suggests the principle of a good health promoter is to motivate people to enable them to make healthier choices; this is made possible by the ability to engage with individuals at all levels. Individuals who are not motivated are unlikely to succeed (Naidoo & Wills 2000).“Advise” patients to stop smoking and reinforce the health benefits to quitting, “assist” the patient to stop, setting a quit date and discussing ways in which nicotine withdrawal can be overcome. Being unable to cope with the physical symptoms of withdrawal can cause relapse and be a barrier to success, therefore it is essential the nurse possesses a good knowledge base of the products available to assist in reducing these symptoms if she is to persuade people to comply with treatment, such as the use of nicotine replacement therapy (NRT). NRT is useful in assisting people to stop smoking and has proved, in some instances to double the success rate (Upton & Thirlaway 2010). NRT products are continually changed and updated; therefore the nurse must ensure she has the knowledge and skills to identify which products are available, the suitability, how it works and any potential side effects. Identifying triggers and developing coping strategies is useful for maintenance of a new behaviour, measures such as substituting cigarettes for chewing gum and changing habits and routines are just some of the ways in which self control can be achieved (Ewles & Simnett 1999). Finally “arrange” a follow up, providing continual support and engagement. For patients who do not wish to stop smoking, advice should be given with encouragement to seek early medical treatment on detection of any signs and symptoms of disease. Good communication skills are essential to the therapeutic relationship between the nurse and a patient and these must be used effectively by providing clear, accurate and up to date information. The nurse should be an active listener and encourage the patient to talk, using open-ended questions helps demonstrate a willingness to listen, listening and showing concern for a patient’s condition demonstrates respect (Peate 2006). The use of medical jargon and unfamiliar words can be a barrier to communication and should be avoided as these can affect a patients understanding. Leaflets can reinforce information provided by the nurse and increase patient knowledge, however the nurse must ensure these are in a format and language the patient can understand. Lack of literacy skills can prevent a patient reading and understanding the content of a leaflet, the nurse can assist with this by reading and explaining to them.

To assist in the assessment process the nurse may utilise a model of behaviour such as Prochaska & DiClemente’s stages of change model (1984). This works on the assumption that individuals go through a number of stages in order to change behaviour, from pre -contemplation where a person has not considered a behaviour change, to maintenance, when a healthier lifestyle has been adopted by the new behaviour.The stage a person is at will determine the intervention given by the nurse; therefore it is essential that an effective assessment takes place. Walsh (2002) highlights patient motivation as central to success using this model, in that a patient will have more motivation; the more involved they are in planning the change.

Despite the health promoting activities mentioned and the increasing public awareness of the health risks to smoking, there are people who continue to smoke and some further develop illness as a consequence. Lung cancer has one of the lowest survival rates, and as little as 7% of men and 9% of women in England and Wales will live five years after diagnosis (Cancer Research UK 2011). Acknowledging this, the governments “Cancer Plan” aimed to tackle and reform cancer care in England by raising awareness of the signs and symptoms of cancer by investing in staff and extending the nurses role (DH 2000). This involves further training and education for nurses to develop their skills and knowledge to enable them to provide the treatment and/or advice required. This was succeeded by “Improving outcomes: a strategy for cancer” the aim being to enable patients living with cancer a “healthy life as possible”.The government pledged ?10.75 million into advertising a “signs and symptoms” campaign to raise awareness of the three cancers accounting for the most deaths, breast, bowel and lung, to encourage the public to seek early help on detection of any symptoms (DH 2011). Currently no results are available on the effectiveness of this intervention due to its recent publication, however, one national policy that has had a positive effect on the health of individuals and the population is that of the “smoke-free England” policy implemented in 2007 prohibiting smoking in workplaces and enclosed public places. Primarily this policy was enforced to protect the public from second hand smoke; however, on introduction of the law smoking cessation services saw an increase in demand by 20%, as smokers felt the environment was conducive to them being able to quit (DH 2008). This policy also extended to hospital grounds, and the nurse must ensure a patient who smokes is aware of this on admission and use every opportunity possible to promote health.

Tertiary prevention aims to halt the progression, or reduce the complications, of established disease by effective treatment or rehabilitation (Tones & Green 2004). A diagnosis of cancer can cause great distress and a patient may go through a whole host of emotions. Naidoo and Wills (2000) suggest the aim of tertiary prevention is to reduce suffering and concerns helping people to cope with their illness.The community nurses role has been identified as pivotal in providing support for patients and families living with cancer (DH 2000). The World Health Organisation describe Palliative care as treatment to relieve, rather than cure, the symptoms caused by cancer, and suggest palliative care can provide relief from physical, psychosocial and spiritual problems in over 90% of cancer patients (WHO 2011).

Assessment and the provision of health education and information at this stage remains the same as that in secondary prevention, and it is not uncommon for the two to overlap. Providing advice and education on symptom control may alleviate some of the symptoms the patient experiences, for example breathlessness is a symptom of lung cancer (Lakasing & Tester 2006), and relaxation techniques may reduce this (Cancer Research UK 2011), therefore the nurse may be involved in teaching these techniques to the patient and family members. Continual smoking despite a lung cancer diagnosis can exacerbate shortness of breath and reduce survival rate (Roddy & Ross 2007), therefore the nurse can use this opportunity to reinforce the risks of smoking. However, the nurse must use her judgement effectively and be sensitive to the patient’s condition, as the willingness to learn and respond to teaching can be affected by emotional state (Walsh 2002). Establishing effective pain control is essential in the care of a cancer patient and this may involve discussion with the patients GP if medication needs adjusting. A referral to specialist help lines such as those provided by Macmillan cancer support may be useful in assisting a patient and/or family to cope with cancer, these services can be accessed in person or by telephone. These are just two examples of collaborative working and demonstrate the importance of inter-professional working.

In conclusion, with the emphasis of health promotion concerning prevention of illness and disease, the role of the nurse is essential in raising awareness and providing education and advice to individuals to facilitate behaviour change. The complexities of health promotion indicate the extensive competences a nurse must possess to empower and motivate individuals. However, governments also have a responsibility to promote and protect health and are pivotal in introducing national policy to build “healthy publics” and environments conducive to health.

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Free Essays

Address a health and social care policy that you believe to have produced transformational change in the delivery of service to patients or clients?


The Choosing Health (DoH 2004) new approach to public health backed by the public will deliver a sustained improvement to the health of the people of England. It will do so by responding to people’s concerns about their health with practical support on their own terms and by providing an environment needed to make real progress.

Recent years have seen significant changes to policy and services in the commissioning and delivery of mental health services. The National Service Framework for Mental Health (NSF) has delivered sustained development and improvement across England.

Reflecting on the past decade, the transformation in the range and quality of services is there for all to see, in real services, new buildings and improved outcomes for patients. These developments have taken place across the health, social care and the third sectors. They have been achieved by organisations working together in partnership and in many cases, integrating service delivery and commissioning.

Putting People First: is a shared vision and commitment to the mental health transformation of adult social care and under this programme, councils must transform their adult social care systems by March 2011. The programme is funded by a ?525 million social care reform grant – available from 2008-2011. Much of the focus is on personalisation; giving more choice over services and control over decision making to individual service users. This policy allows personal budgets allocated to users on the basis of need, from which they will fund care services. The policy also is a strategic shift from reaction to prevention, promoting independence for the mental, older and disabled people. The policy set up information and advice services to be available to all users and care.

Government White Paper – Our Health, Our Care, Our Say

In April 2006, the Government published the White Paper “Our Health, Our Care, Our Say”. Its publication followed the largest public consultation in England concerning the future direction of healthcare. The White Paper recognised the ongoing challenges faced in this country as a consequence of increasing rates of obesity, diabetes, cardio-vascular disease, and the impact of mental illness, with estimates of around 15 million people now suffering from these types of long term conditions.

Around 5 million people were recorded to be suffering from work-related stress, with a ratio one to six adults considered to suffer mental health problems ‘at any one time’, One out of four patients consults their GPs concerning their mental health, and mental ill health is reported to the key reason for 865, 900 adults to be dependent on Incapacity Benefit in England (DOH, 2007b). Around 5 million people were recorded to be suffering from work-related stress, with a ratio one to six adults considered to suffer mental health problems ‘at any one time’, One out of four patients consults their GPs concerning their mental health, and mental ill health is reported to the key reason for 865, 900 adults to be dependent on Incapacity Benefit in England(DOH, 2007b).

The goals of Our Health, Our Care, Our Say: are expected to be achieved through,

practice based commissioning, shifting resources into prevention, More care undertaken outside hospital and in the home, better joining up of services at the local level,encouraging innovation , allowing different providers to compete for services

The nature of provision has also been altered with the advent of Foundation Trusts and the greater engagement of the independent and voluntary sector in the provision of services.

The environment in which commissioners and providers operate is now one that is more fluid and dynamic than ever before. It is an opportune time to consider what can be learnt from the experience of integration and what role it will need to play in the future commissioning and delivery of mental health services.

Integration describes the coordinated commissioning and delivery of services and support to individuals in a way that enables them to maximise their independence, health and wellbeing. Coordination of this type is especially important for people with mental health problems who often require support from a variety of organisations or individual care workers. The delivery of integrated care is influenced by the practice of staff, the systems they work within, how users are engaged and the structure of organisations.


Putting People First: A shared vision and commitment to t

The National Service Framework for Mental Health was published in October 1999. It is a 10-year plan for the modernisation of mental health services, and sits alongside the NHS Plan.

The main provisions of the Mental Health Act 2007 came into effect on 3 November

2008. The direction of travel for health care services in broad terms and can be characterised by a renewed focus on primary care and prevention rather than just curative and reactive interventions and

dGuidance/DH_4009598) .

Mental Health is recorded to be the second prime cause of death in men between ages 14 to 44 through suicide, and the prime cause of suicide among young men .The cost to society in human, social and economic terms is significant; poor mental health is the cause of increase in health-related benefit claiming production lost through time off due to sickness and the cost of treatment and sick pay recorded is reported to cost the economy between ?30 billion and ?40 billion per year. (National Mental Health Development Unit[NMHDU]


Putting People First: A shared vision and commitment.

The focus has been on transforming services through integrated working across health, social care and the third sector and represented the key guidance influencing those delivering mental health services at a local level, and has been the basis upon which their work is evaluated.

Transformational changes in the delivery of mental health brought together key areas of policy, increasingly addressing the mental well-being of communities as a whole and extending the progress made to date across all age groups, and to more marginal ones, such as offenders.

DOH (2007) further helped transformed mental health through broader NHS priorities helping shaping services, with themes such as health inequalities, the value of carers and dignity in care all contributing to an ever improving service

The Choosing Health (DoH 2004) policy has three core principles. Firstly ‘informed choice’ which enables people to make their own decisions and choices that impact on their health and to credible information to help them do so. People agree that there is need for special arrangements for those cases where one’s choice may cause harm to another for example exposure to second hand smoking. Secondly ‘personalisation of support to make healthy choices’: support has to be tailored around people’s lives and ensuring equal access to them. Thirdly ‘working together to make health everybody’s business’: real progress depends on effective partnerships across communities, including local government, the NHS, business, voluntary sector, faith organisations and many others. The government will lead, coordinate ands promote these partnerships and expect others to engage constructively. Choosing Health (DoH 2004) also acknowledges the fact that the environment we live in, our social networks, socio economic circumstances and resources in our local neighbourhoods can affect our health. According to the Choosing Health (DoH 2004) policy the consultation process established a set of priorities for action which included: reducing the numbers of people who smoke, reducing obesity, improving sexual health, improving mental health and reducing harm and encouraging sensible drinking. This set of priorities is lifestyle and behaviour which lead to preventable diseases Griffiths and Hunter suggest that improving health in communities and reducing preventable diseases lessens the burden on the NHS and freeing it up to provide better services for those with unavoidable ill health.

Choosing Health (DoH 2004) outlines a broad based social marketing strategy which focuses on engaging individuals, organisations and broader society to bring together messages that raise awareness of health risks with information about action that people can take to improve their health. Action has been linked to activities in the communities, schools, public places and workplaces and focus has been placed on the set of priorities.

Personalisation is a key strand in current and emerging health and social care policy.

The message is being put out with personalisation is simple, cost effective and has transformed many and changes lives.

The NMHDU are working together to achieve shared goals

The NMHDU will continue to promote the needs of people with dual diagnosis, as an integral part of its work. In particular, the Improving Care Pathways programme lead will be scoping further opportunity to collaborate with other programme areas, including the national Alcohol Improvement Programme (AIP) and offender health programmes, to strengthen links across to mental health.

Since the publication of “High Quality Care for All” in June 2008, monitoring and incentivising better quality of care and better user outcomes has been a leading part of the Government’s agenda for the NHS

Mental health has received high priority during the period of NSF implementation. The end of that period should not be seen as an ending of the work to improve either the range or quality of services. The challenge now is to utilise the power of integration to ensure that mental health is placed at the centre of local service development and delivery, coupled to an increasing focus on well being

Local Implementing Teams in mental health have successfully brought together commissioners, providers, the third sector and service users to shape priorities, drive delivery and monitor progress. They have demonstrated the benefits of engaging diverse stakeholders to achieve change, and are an example of the opportunities that integrated working can bring. Integrated working can offer the opportunity for health and social care to operate equally, breaking down traditional barriers and creating seamless services. In particular, it provides the chance for the role of social care to be enhanced and recognised as a key contributor to the planning and delivery of services ( ICN 2008).

The policies brought changes and good practice in delivering mental health and as a result ten GP practices are working together to integrate community mental health teams, based in a rural location, with a single point of access from GP practices. This project will integrate acute and social services and aim to remove boundaries so service users can more easily navigate their way through the system and avoid repetition of the history to numerous professionals. :


Department of Health (2004) Choosing Health: making health choices easier. Cmnd 6374. London: The Stationery Office.

Department of health (2007) Putting People First, a shared vision & commitment to the transformation of adult social care. London. The Stationery Office.

NIMHE ( 2003 ) Positive approaches to the integration of health & social care in mental health services,

National Mental Health Development Unit [NMHDU] (n.d) New Horizons-Working together for better mental health [Online] Available: at <]

A guide ICN ( 2008) Bringing the NHS and Local Government Together, Integrated working:

NatPACT (2005)The Commissioning Friend for Mental Health Services

Bogg, D. (2008) The integration of mental health social work and NHS, learning Matters.

Glasby, J and Dickson,H. (2009) International rescue – Community Care


Integration and mental health (2009)Integrated care, London Stationery.

National Mental Health Development [Available on line

dGuidance/DH_085825 Putting People First: A shared vision and commitment to t and

Guidance/DH_4009598 Publicationsandstatistics/Publications/PublicationsPolicy; The goals of our health, our care, our say

Free Essays

Public health is termed as the knowledge and skill of avoiding illness, extending fitness


According to Acheson report (1988) Public health is termed as the knowledge and skill of avoiding illness, extending fitness in the course of a planned hard work of the community that is the idea and the hard work of the society will concentrate policy matters at the point of the general health of the people (Orme et al., 2003).

Weber described class as “a number of people who have in common a specific causal component of their life chances in so far as this component is represented exclusively by economic interest in the possession of goods and opportunities for income, and is represented by under the conditions of the commodity or labour markets” (Townsend, 1974, p.128)

19th Century Housing

According to Orme et al., (2003); Ineichen (1993) ; Burnett (1978) and Lambert, (2008) accommodations in the 19th century were extremely poor, overcrowded and unhygienic many homes were not properly constructed, and they were full of waterlogged and were unhealthy for human that is there were no illuminations; no airing in the house, in a typical home there were no furnishings in the individual homes, households had to share only one bed; that was mostly seven to nine individuals were sleeping in the same room and bed and the fact is these were usual practices around the time and sanitation had always been poor since the 18th century and much poorer as the numbers of people living in the same room increased and this contributed to the distribution of infectious illness which included cholera, typhoid and typhus.

Meanwhile there were no set of laws to construct a house in many cities. Building constructors usually constructed houses as they want and they mostly build a lot of properties in a single land. Several homes were ‘back-to-backs’ which means the back of one house was attached to the back of the other and were often two or three rooms, the sad thing was they were all cellar dwellings and cities such as Liverpool households stayed in cellars, which were soggy and inadequately ventilated as well as packed. Extremely poor individuals dozed on straw as they could not have the funds for beds (Lambert, 2008; Burnett, 1978; Ineichen, 1993) and Cholera around that time was very contagious which led many to a serious intestinal illness the incidence of cholera was very fast which took the lives of twenty- two thousand people the warning signs were aggressive diaheohoa with vomiting led by severe pain in the arms, legs and the stomach. Persistent dehydration and fever were frequent with the sickness and warning signs were very speedy within three to twelve hours and the skin turned dry and a cloudy navy or purple in colour whiles the individuals eyes sucked in their holes (Lambert, 2008; Burnett, 1978; Ineichen, 1993).

Within 1848-1849 cholera took over 50, 000 – 70, 000 lives and was a major public concerned. (Orme et al., 2003; Ineichen, 1993; Burnett, 1978)

Moreover, Baggott, (1998) confirmed that the early 19th century had lots of voluntary hospitals that were set up by those who gave funds to the public. The status of the voluntary hospitals were such that doctors did not have to charge for treatment with the concession of allied with the hospital, but doctors were making a living by treating the rich investors whose donations sustained the hospitals. The rich were always treated in their houses instead of the hospitals and hospitals in the 19th century were chiefly for the poor who could not have enough money for treatment. However, permission to these hospitals was very discriminative in such that the poor and the individuals with contagious illness were often refused entry since the doctors were not getting any money from them (Baggott, 1998).

According to Orme et al., (2003) Ineichen, (1993) Burnett (1978) Lambert (2008) it was a very sad moment when a member of one’s family could only be seen for a few days or hours after woken up an in 1843, Individuals could not live for more than 26 years in Liverpool, 37 years in London and 40-45 years in Surrey and many children lost their lives prior to their fifth birthday (Ineichen, 1993) and incidence of contagious illness were considered as miasma theory, which stated that illness came as a result of inhaling toxic substances which was the main focused of the Victorian public health groups, when incidence began to worsen (Ineichen, 1993). In 1832 the Royal Commission on the poor Laws were chosen as the concerns for public health rose very high with an increase in the cost of public funds which was followed by outburst of illness (Ineichen, 1993) it was not until 1840 when one Edwin Chadwick who was a famous supporter for social justice and the overall development of sanitary situations in the neighbourhood as a whole with decided to look into why there were a lot of contagious illness and according to Chadwick, the outbreak of contagious sickness were owed to poor sanitation, he recognised the fact that high levels of poverty were the grounds for individuals not being able to meet the expense of living in a cleaner environment however, individuals were really cleaning within as well as ingestion from polluted water supplies. In 1840, Chadwick had a strong-willed that something had to be done by investigating on his own. By 1842 Chadwick who was the Commissioner to the Poor Law ultimately issued a statement on the Sanitary Conditions of the Labouring Population of Great Britain. The statement accused the poor sanitation and overcrowded homes as the cause of illness. Chadwick assumed that the awfully standard of living of the poor gave way to the prevalence of illness; therefore he made careful observation on the way of life of individuals. Chadwick’s came up with a conclusion that the poor sanitary condition was the cause of illness in the community but his analysis also he made it know that a well developed procedures must be in place so as to resolve the lives of the un-wealthy individuals in the society and the procedures were to run sufficient drainage and water systems. Chadwick also added that all refuse must not be stored in homes and roads so as to reduce the spread of illness in the community (Ineichen, 1993). It was not until the hub of 1800s when one physician John Snow , who was managing the incidence of cholera in Broadgate which was a poor suburb in London assessed the effect of the illness from one area to another and made it known that drinking from polluted water was the cause of the incidence of illness such as Cholera rather than inhaling polluted scent from the atmosphere and as a result, a new legislation was passed when Chadwick revealed his 1842 report which made it clear that poor standard of living were the cause of the major incidence of illnesses in town which led majority of people to be occupied in cellars as a result of the government driven them out of their homes in 1851 to stop overcrowded (Orme et al., 2003; Ineichen, 1993; Burnett, 1978; Lambert, 2008). Many men groups named Paving Commissioners or Improvement commissioners were set up with the rights to tile, sanitary and illuminate the roads but in those times England was separated into parishes therefore the Commissioners merely had rights over specific parishes ( Burnett, 1978; Ineichen, 1993).

However in the 19th century many new houses were constructed which expanded to other parishes where the commissioners had no rights in the new neighbourhood their roads were normally untilled with no lights on the streets. They had no drainage systems and when it rained roads curved into sludge. Individuals were splashing unclean water in the roads which left stagnant on the roads, toilets outside the homes and were normally used by more addresses, there were usually long lines especially on Sunday mornings to use the toilets (Lambert, 2008; Burnett, 1978; Ineichen, 1993).


In the nineteenth century the living condition of the British civilization was extremely poor (Rose, 1982) take home pay per every individual was ?45 in 1900 and ?57 pounds in 1938. Many individuals who were able to work fell into poverty at some point of their lives and poverty was considered as part of the civilization. Even individuals with the maximum paid could come across in a time of work dejection. As work was very difficult to come by even if you were desperate and determined to do so. Even an artisan at some point had to depend on the incomes of children, help from friends, or borrowed money from neighbouring tradesmen so as to make ends meet before things get better. A bigger percentage of the British population straggled to make ends meet and their level of poverty were more constant even if it was not everlasting one (Rose, 1982), that is pauperism and misery was considered as a collective problem but not poverty.

Later in the 19th century plans were made to reconstruct the public health professionals were allotted and assisted to develop the drainage systems, accommodations and roads. Individuals started to realise about the effects of good hygiene. Florence Nightingale went on an assignment to develop hospital environments whiles Joseph Lister also revealed that many contagious illnesses came as a result of unsterile instruments used in surgery therefore he started cleaning apparatus after surgery this reduced the number of contagious deaths during surgery operation from 60% to 4% since then individuals were able to live longer after discovery of personal hygiene. ….

The public sector had the biggest share of hospital

Political Reforms

According to Lambert (2008) the Tory regime was set up in 1822 which then initiated a number of reforms at that moment, individuals could be suspended for more than 200 crimes however in 1825-1828 the life sentenced was eradicated for than 180 offences.

The Industrial Acts

Lambert (2008) has confirmed that an industry is termed as an environment where over fifty individuals are engaged with the aim of developing a mass product or material. The industrial revolution formed a unique order for women and child labour. Children were always working together with their families but prior to the 19th century children normally did part time work in fabric industries with women and were usually asked to do lengthy hours normally 12 hours or more in a day. The government was aware of the problem and in 1819 a law was passed to make illegitimate for children less than nine years of age to be employed in fabric industries. On the other hand the law was not very effective as there were no assessors to monitor the industries for unlawful children working. Therefore in 1833 a new law was passed for supervisors to monitor the fabric industries to stop children below the age of nine from labouring in the fabric industries. Children who were aged nine to thirteen were also not permitted to do more than twelve hour shift aday or more than 48 hours within seven days and Children aged thirteen to eighteen were also not to do more than 69 hours within seven days. Moreover no one below the aged of eighteen was permitted to do late night shift that is between 8.30 in the evening to 5.30 in the morning but within 1844 another act passed to disallow female from doing more than twelve hour shift within 24 hours which also decreased the minimum working age for operating in the fabric industries but in 1847 females and children were stopped from doing over ten hour shift within twenty four hours in the fabric industries.

In addition to the reforms, in 1850 the law was modified to permit females to work for ten and halve hours a day meanwhile fabric industries were not to be operated for more twelve hours within twenty four hours a day and every employee together with men, were authorized to take one and half hours for meal breaks however, In 1867 the law was expanded to all industries not only fabric industries however the1878 Factory Act explained an industry as any environment where equipment are used in processing materials. Moreover, in 1842 Miners Act was passed which prohibited females and children below the aged of ten from going underground to do mining work(Lambert, 2008).

At the middle of 1860s the ten hour shift a day was very normal, but not worldwide. In ‘sweated industries’ for instance manufacturing of matchboxes and fasten and individuals were getting more wages for ever single they completed many were working from their residence and usually worked from sunrise till sundown to make ends meet. All the same in 1871 bank holidays were formed and In the 1870s a number of professional employees were assigned an annual seven day vacation with pay. (Although it was not until 1939 that everybody had annual paid holidays) but in 1890s it was general for most individuals to have the weekends to rest especially Saturday afternoon(Lambert, 2008).

Trade Unions in the 19th Century Between the 1799 and 1800 the regime conceded the Combination Acts, which prohibited men from doing more than two jobs so as to make more earnings but in 1824, the combination acts were abolished but it was still not certain whether trade unions were officially authorized to make laws and was not until 1871 that trade unions were certainly made lawful.

Moreover, In the 1850s and 1860s qualified employees created temperate trade unions named New Model Unions which employees had to make donations towards the union and in turned received illness and job loss benefits and the New Model Unions were devoted and regarded as highly professionals who tried to consult instead of thump it was not until 1868 when TUC was established (Lambert, 2008)..

Moreover, in the late 19th century unqualified employees started to structure an influential trade union and in 1888 one Annie Besant tried to arrange a thump between females who toiled in Bryant and May industries to produce matches the reason was that the girls were getting low wages from working with them and experienced a sickness named ‘phossy jaw’ which comes as a result of operating with phosphorous. The strike went well and the companies were asked to increase their wages and in 1889 the girls created a trade union to protect their rights at work (Lambert, 2008).

Meanwhile In March 1889 individuals working for Gas companies and common Labourers also created a union whiles on the 14th August 1889 employees from the Great London Dock also had an achievable thump for five weeks for increase in pay (Lambert, 2008)

Professional employees occupied in ‘through’ addresses, as the name implies it means one can stroll through them from front to back. Meanwhile in the 1840s town councils started to make enforcements on houses. Cellar houses were prohibited and the style back-to-backs could not be constructed anymore but it was not viable to destroy and restore them all at ago. It took many years and many were still occupying in back-to-backs in the 20th century (Lambert, 2008; Burnett, 1978).

Still at the beginning of the 19th century toilets were usually cesspits, which were not regularly drained and from time to time spilled over while urine could leak through the floor into holes from which individuals got drinking water. This led to the spread of contagious illness such as cholera in many cities in the1831-32, 1848-49, 1854 and 1865-66 and in 1848 a Public Health Act was imposed. The act made it obligatory to structure local Boards of Health in towns and where the annual mortality rate will surpass 23 per 1,000 or if 10% of the population wanted it. Local Boards of Health could claim that all new homes get waste pipes and toilets. They would also arrange a water supply, street cleaning and waste collection. And In 1875 a Public Health Act was reinforced over the old acts where every local authority were asked to nominate Medical Officers of Health who would be responsible for taking legal action over individuals who sold polluted food or drink which was unclean to be utilized by individuals and local councils were made compulsory to offer waste collection (Lambert, 2008).

Town councils started to make public parks available and a lot were approved by-laws, which set down the least standards for new homes. However in the 1860s and 1870s sewers were dug in many big towns and In the 1870s water supplies were installed in many towns which led to much better and hygienic environment at the later part of the 19th century than earlier stage whiles in 1875 the Artisan’s Dwellings Act was conceded, which enabled councils the right to destroy poor areas but authorization to destroy huge range poor areas could not start until the 20th century. (Lambert, 2008)

Also in the middle of the 19th century the standard of living grew up. And by and by homes developed bigger. And In the end of the 19th century ‘two-up, two-downs’ were frequently seen that is homes with double bedrooms with a kitchen and ‘front room’ and most professional workers occupied in addresses with three bedrooms. Meanwhile at the later part of the 19th century very few poor households were still occupying in only a single room (Lambert, 2008)

The Poor Law

In 1792 well known magistrates met at Speenhamland in Berkshire and formulated a scheme for helping the poor. Minimum salaries were added to cash heaved by a poor charge. Several neighbourhoods of England implemented the scheme but it beard out to be very costly and the government however determined to make some amendments. In 1834 the Poor Law Amendment Act was conceded. In future the poor were to be handled as unkindly as possible to discourage them from getting aid from the country. In future able bodied people with no income were to be forced to enter a workhouse. (In practice some of the elected Boards of Guardians sometimes gave the unemployed ‘outdoor relief’ i.e. they were given money and allowed to live in their own homes).

For the unfortunate people made to enter workhouses life was made as unpleasant as possible. Married couples were separated and children over 7 were separated from their parents. The inmates were made to do hard work like breaking stones to make roads or breaking bones to make fertiliser.

The poor called the new workhouses ‘bastilles’ (after the infamous prison in Paris) and they caused much bitterness. However as the century went on the workhouses gradually became more humanitarian (Lambert, 2008).


Ashforth, D., Digby, A., Duke, F., Flinn, W.M., Fraser, D., McCord, N., Paterson, A., Rose, E.M. (1976) the new poor Law in the Nineteenth Century Macmillan: London

Baggott, R. (1998) Health and Health care in Britain (2nd Ed) Macmillan: Basingstoke

Burnett, J. (1978) a Social History of Housing 1815-1970 David and Charles: Vermont

Englander, D. (1998) Poverty and poor Law Reform in 19th Century Britain, 1834-1914 From Chadwick to Booth Longman: London

Ineichen, B. (1993) Homes and Health: How Housing and health interact Chapman & hall: London

Lambert, T (2008) England in the 19th Century 23.03.11)

Orme, J. Powell, J. Taylor, P. Harrison, T. and Grey, M. (2003) Public Health for the 21st Century: New Perspectives on policy, participation and practice Open University press: London

Rose, E.M. (1982) Studies in Economic and Social History: The Relief of poverty 1834-1914 Macmillan: London

Townsend, P. (1974) the Concept of Poverty Heinemann: London

Free Essays

Health and safety issue for contractor company in oil and gas industry


Exploration and production of petroleum is highly profitable sector, but on the other hand, it is very risky business. Catastrophe in refineries and oil rigs like Mexico II (1983) in the Gulf of Mexico, Pipe Alpha, has totally changed the script of safety procedure and risk assessment. It is evident from the past history, 65 % of disasters resulted due to Human Organizational error. That’s why it is highly recommended to the oil operating and contractor companies to identify the risk, potential hazard and consequence of hazardous incident.

Health and safety measure are always seems to be an overburden for project, but in reality they are preventing the tragic accident which would be result in damage of assets, loss of valuable human lives, demoralization of team and hazardous environmental impact. In last 35 years of North Sea, average yearly accidental cost is ?200M (except in 1988-1989 cost ?1200 M due to Piper Alpha) and loss of 485 precious human lives (ROYAL INSTITUTION OF NAVAL ARCHITECTS 1991). In this report, we will try to discuss the critical issues of health and safety faced by a contractor company in oil industries. Furthermore, we will try to show what was done wrong in past and will try to suggest how similar incident might be prevented in the future.


“Nation have passed away and left no traces, Any history gives the naked cause of it – one single simple reason in all cases; they fell because their people were not fit.”Rudyard Kipling.

Unfortunately, the history of the oil and process industry indicates that a lot of incidents are repeated after a lapse of a few years .Because people move and lesson are forgotten. Accidents caused during the following activities are very common, many of them are not resulted in death, serious injury or serious damage – they were near-miss. But they could have had much more serious consequence. We will discuss few of them in detail.

Isolation of Equipment.
Accident caused by Human Error
Entry to Vessel
Liquefied Flammable gases
Storage Tanks
Pipe and Vessel Failure
Hazard of Common Material
I don’t know that (Like Ammonia can explode, Hydraulic pressure can be hazardous, Diesel engines can ignite leaks.

1. Isolation of Equipment:

Case I:

Three people were killed and the plant was destroyed during a pump repair. Dismantling was done to repair the pump. When the cover was removed, hot oil, which is above its ignition temperature, came out and caught fire.

From several days, a pump was waiting for repair work and work permit was issued. On the day of accident, the foreman who issued the permit should check the drain valve should be opened and suction & delivery valves were shut. But suction valve was opened and drain valve was closed by someone. Maintenance team only intend to change the pump bearing and they decide to open the pump and inform the process team but no further checks and isolation was done.

It is not habitual in company concerned to isolate the equipment under repair by slip plate, only by close valves. Similarly, failure in permit to work procedure was the major reason for the disasters of Piper Alpha.


Permit to work will be withdrawal and new one is issued, if there is any change in the nature of work.
Isolation of equipment must be done when it is under repair.
Bleed valve and double blocks must be installed, where fluid at having gauge pressure above 600 psi or temperature above or near auto-ignition point.

2. Accident caused by Human Error:

Case I: (Warning Ignored)

During the working shift, it had been noticed by the operator that the level of fluid in tank is falling rapidly. He informed the instrument department that the level gauge is not working properly. After few hours, when they were changing the gauge, they found that the previous gauge was correct and there was a leaking in the drain valve. But it is quite late and they has been lost 10 ton of material.

Case II: (High Temperature Alarm)

After a modification pump was installed, it was used to transfer some liquid. When the transfer of liquid completed, operator pressed the switch off button, he saw the pump is “running off” light went out.

After a several hours, high temperature alarm of pump sounded. Operator supposed that there was a fault in alarm and he ignored it. Soon afterward, there was a huge explosion in the pump. During the modification of pump, an error in the circuit was introduced and stop button was not working properly.


Proper training should be given to the operators; they must take a necessary action upon unusual reading.
Always respond to alarm. They might be correct. Training should be emphasis the importance of alarm.
In record sheet, control limit must be defined.

3. Entry to Vessel

Many incident have been happened which killed no of peoples because they entered inside the vessel or any other confined space which had not been thoroughly cleaned or tested.

Case I: (Unauthorized Entry)

Contractors mostly unfamiliar with the operating companies rule, have frequently got into the vessel without authority. A contractor foreman entered in a vessel which was opened and disconnected, setup for entry, but it was not yet tested. The foreman was estimating the cost of cleaning, he supposed that there was no need of permit for entering the tank just for inspection and got affected by the gas.

Similarly an incident happened during the lunch time, a process foreman was taking a last look of vessel before boxed up. There was an old gas mask lying on the floor, he decided to go and remove it. While going inside he slipped from the ladder and fell and was knocked. His tongue blocked his throat and he suffocated.

Case II: (Entry into vessel with Irrespirable Atmosphere)

A contractor entered in the combustion chamber of a gas plant watched by two standby men but without waiting for the breathing apparatus to arrive. He lost consciousness halfway up when he was climbing out of the chamber. He was hanging between the chamber wall and the ladder. Rest of the men could not pull him out with lifeline. One of the men reached to the person without breathing apparatus and he also lost consciousness. Both of them were rescued, but standby man was died by this time.

Case III:

Vessel was generally split up into two halves by a baffle which had to be removed. The vessel was cleaned out, inspected, and a permit issued for a worker to enter the left hand side of the vessel to burn out the baffle. It not possible to see on the right hand side of the vessel but as the left hand side of the vessel was clean and because no combustible gas was detected it was assumed that the other half was also clean. While the welder was in the vessel, some deposited in the right hand half caught fire. The Welder came out side without a sever injury but wounded himself in his rush.


Vessel should assume to contain hazardous material, if a portion of the vessel can not be tested and it seems to be safe.
Only gas test are not enough. When the vessel will be heated or disturbed it may produce gas which was present in the sludge.
For any addition work inside the vessel, new work permit for confined space should be issued.
People should now put their head inside the vessel unless entry has been authorized.
Manhole should be covered with barrier if the vessel is opened but entry is not yet authorized.
Rescue person should be available at the spot with necessary equipment.
Always use breathing apparatuses before entering the vessel.
Do not relay on contractor reading rule, just follow the safety procedure of operating company.

4. Liquefied Flammable Gases:

Case I: (Fire and exploration at processing plant at Mexico City)

November 1984, there was a worse incident at processing plant (LPG-actually Propane 20 % and Butane 80%) in San Juanico, Mexico. About 542 people were died, 4,248 were injured and 10,000 become homeless.

The main cause was the rupturing of 8 inch line. During investigation it was revelled that the tank was overfilled and the inlet pipeline was overpressure. It is not known why the pressure relief valve was not lifted. The gas was spread in the area of 200m by 150 m before it caught fire. Most of the people got killed and injured are pubic, who were living near the plant.


There was not gas detector in this area. This should be present.
Plant was at congested place about 160 m away from town. It is recommended that for LPG plant it should be 600 m away from the town.
There was no fire insulation on equipments. Vessels and tank should be fire insulated.
The water deluge system was inadequate.

5. Modification:

Many accidents have happened just because modifications were carried out in plant and these modifications were not fulfilling the safety criteria.

Case I:

A reactor was cooled by a providing of brine to the jacket. There was a repair work in brine system and it was to be shutdown so water from town was used instead. This town water pressure (130 psi gauge pressure) was more than that of brine, so the reactor collapsed.

Before the modification, a modification approval form was approved which had twenty important questions. But this form was filled as a formality.


Before modification, however inexpensive, temporary or permanent, is made to a plant or process or to a safety procedure, it should be authorized in writing by a manager and an engineer.
They manager and engineering who authorized modification can not be expected to stare the drawing and hope that the consequence will be show up. They must provided with an aid such as a lost of questions to be answered.
The foreman should not be authorized to make any modifications at field work.

We have discussed few of the above critical issues which are very important for a contractor company to work in oil and gas industry. Furthermore, critical issues of a plant are also indicated in logical tree analysis in figure 1.


The purpose of this report is to indicate the safety issues for a contractor company in oil and gas industries. The purpose of giving the cases and recommendation is to understand what they had done wrong in the past and to advise how similar disaster might be prevented in the future. After reading this report just analysis your plant, are you doing the same wrong thing which people did and resulted in disastersDevelopment of a safety culture is necessary, culture which would be committed with safety; safe work practise would be encourage and people do insist for safe work for every one, their attitude must be toward safe work practise. Leadership and top management should have to set a meaningful safety program by providing sufficient training and experience. Moreover, communication played a significant role; proper training and safety induction should be given to supervisor level, so that the correct information should be transmitted to them.

Figure no. 1 Logic Tree Analysis


The integration of Quantitative Risk Assessment and Reliability centered Maintenance to optimize platform Design and Operations by R.M Marshell, S.T.Maher, P.R. Stevenson & B.C.Morris

Free Essays

Obesity is an increasing global health problem, and one of the leading preventable causes of death


Obesity is an increasing global health problem, and one of the leading preventable causes of death. The definition of obesity taken from the NHS website is; Obesity is when a person is carrying too much body fat for their height and sex. A person is considered obese if they have a body mass index (BMI) of 30 or greater . The main problem here is that there is numerous health problems linked to obesity, therefore if Obesity is helped and reduced, it would be like solving the root to the numerous health problems it is linked to. In other words instead of tackling the health problems that are caused by obesity, you tackle obesity itself which would then in theory lead to a general decrease in obesity related health problems. This will not only be beneficial to the patients, but in this current economic climate will save the medical sector money that they would use on treating obesity related health problems.

Obesity is a medical condition in which an excess amount of body fat has accumulated within the body to an extent that it may have a harmful affect on health. This can in turn lead to reduced life expectancy and an increased risk of cardiovascular disease. The main problem here is that obesity increases the risk of many physical and mental conditions however regardless of this it is increasing and needs to be tackled. The main cause of obesity is a combination of excess food energy intake and a lack of any physical activity however there are cases when the cause is due primarily to genetics, medical reasons or psychiatric illness. In contrast increasing rates of societal level obesity is thought to be due to an easily accessible and palatable diet, increased reliance on vehicles and mechanized manufacturing.

There are three main ways obesity is being tackled, and it is these three solutions that I am going to focus on in my study.; Diet, Surgery and Drugs. The main solution I will focus on will be surgery.

Diet – Alternative to Surgery

The classic approach to tackle obesity is a low-calorie diet; this still remains the core treatment of obesity.

These diets have the best short-term benefits.

There are three types of low-calorie diets that can be distinguished:

Personalized and moderately restricted diet: This is dependant on a pre-therapeutic assessment. This diet takes into consideration the daily energy expenditure of each individual including their professional and family environment and their food habits. The desired level of caloric intake will equal to two thirds of the average energy expenditure; 1200 – 2000 calories per day.
Low-calorie diet: Total caloric intake averages 800 – 1200 calories per day. This is a considerable reduction in the individuals daily intake and can not be maintained for a long period of time as the patient’s physical activity is hindered and the body is faced with nutritional deficiencies. This ambitious treatment is proposed during hospitalization.
Very low-calorie diet: This is a less than 800 calorie per day diet also known as a protein diet. The medical follow up to this must be very accurate.

Cutting off the usual supply of calories the body gets causes the body to break down fat in order to supply itself with energy thus causing the patient to lose body weight. This dietary treatment is effective for short term benefits however requires a lot of dedication on the patient’s behalf.


A laparoscopic adjustable gastric band also known as a lap band is an inflatable device made of silicone that is placed at the top of the patients stomach through laparoscopic surgery. Laparoscopic surgery also known as Keyhole surgery is a modern technique of surgery in which operations that take place in the abdomen are carried out through small incisions, usually measuring from 0.5-1.5cm. This type of surgery uses images displayed on a monitor which can be magnified. Keyhole surgery is a very beneficial and efficient procedure as the patient feels less

pain and discomfort and recovery time is considerably reduced.

Gastric banding is the least invasive surgery of its kind however it carries the usual risks of any gastrointestinal surgical operation. The patient’s intestines are not re-routed as the stomach is not staples or removed therefore the patient is able to absorb nutrients from food in a normal procedure. Gastric bands are able to stay without causing harm in the patient’s body as they are made entirely of biocompatible materials.

They way this procedure works is that the gastric band is placed on the top portion of the stomach using keyhole surgery. The placement of the band creates a small pouch at the top portion of the stomach. This pouch approximately holds about half a cup of food, in contrast to its normal six cups of food. The pouch fills up quickly; this is where the band comes into effect. The band causes food to pass slowly from the pouch into the lower part of the patient’s stomach. As the upper part of the stomach fills the brain is sent a message that the stomach is full therefore the patient’s hunger dies. This causes the patient to eat a reduced amount of food and stay full for a longer period of time thus decreasing overall caloric intake which can lead to a decrease in weight over time. As the patient starts losing weight the gastric band will need to be adjusted to ensure effectiveness and improve comfort. It is adjusted using a saline solution introduced through a small access port placed underneath the skin. To avoid damage to the port membrane and prevent leakage a specialized non-coring needle is used.

This graph has been taken from and gives an overall idea of the extent to which a gastric band can help weight loss.

According to the study participants who had a gastric band lost 22% of their body weight in two years in contrast to the controls who in which only lost just 6%. This resulted in the ‘gastric band group’ to be healthier and happier.

This is one proof of evidence that shows that this type of solution to tackle obesity is highly effective.

I do not believe taking drugs alone such as AMPHETAMINES is effective as there are many side effects and there have been many cases where patients have become addicted and dependant on the drug itself therefore I do not look at this as a solution personally.

Gastric Banding I believe is the most appropriate as it shows and has been proven to considerably decrease body weight and help obesity. And being a laparoscopic surgery rather than open it has its many advantages;

Reduced chance of needing blood transfusion as haemorrhaging is reduced.
Small incisions are used which reduce pain and discomfort to the patient. In addition recovery time is reduced along with less post-operative scarring
Less pain due to small incisions also means that less pain medication is needed
Procedure times are slightly longer however, hospital stay time is less often same day discharge. So patient can be back to everyday life more quickly and efficiently.
Exposure of organs is reduced due to small incisions therefore chances of contamination and disease are reduced.

However it does come with its disadvantages;

Due to the small incisions the doctor has a limited range of motion at the surgical site. Dexterity is lost.
Poor depth perception
Tissue can be damaged due to tools being used rather than hands.

However I believe the advantages outweigh the disadvantages so keyhole surgery is a effective and efficient solution.

However I believe the advantages outweigh the disadvantages so keyhole surgery is a effective and efficient solution.

There are many risks that come with this type of surgery as with any type of surgical operation.

The biggest risk is from an instrument called a trocar. Injuries are caused to either blood vessels or small or large bowel. This risk is increased with patients that have a history of prior abdominal surgery.

Benefits of gastric banding compared to other bariatric surgeries.

There are many benefits of gastric banding compared to other bariatric surgeries. Mortality rates are considerably lower; 1 in 2000. Due to small incisions, keyhole surgery recovery times are very short along with a short hospital stay. These benefits can make the surgery greatly appeal to the patient as along with losing weight, the pain and overall time is small.


[1.5] Google images.

[2.5] Wikipedia. AS Biology CGP Revision Guide. – overall knowledge

[3.5] Dr Patrick Jordan .










Free Essays

The major national health problems straining the health care system


1.1 Drugs of abuse

Substance misuse is rife in many countries and is one of the major national health problems straining the health care system in England as the number of drug-related hospital admissions due to both legal and illicit drugs increased by 5.7% in 2010 compared to the previous year.1 Drug abuse is generally defined as the excessive or repeated use of drugs other than those for which they are indicated for leading the user to social, physical, emotional, mental and job-related problems.2 There are many factors which can influence drug misuse such as societal attitudes, availability, cost and legal status.

St George’s University of London last year revealed that the number of drug-related deaths reported in the UK rose by 11.8 per cent to 2,182 in a year, whereby the deaths were mainly a result of drug overdose.3 It is evident that substance abuse not only contributes to illness, disability and a continuous rise in the annual drug-related deaths but it also places a huge burden on the economy costing the Government approximately ?1.2 billion a year.4 This includes measures aimed at tackling problem drug use through education, rehabilitation programmes, as well as fighting drug-related crime.4 Problem drug users are not only a threat to themselves but also to family/friends and to society as a whole. This indicates the magnitude of problems they can cause, which is another reason for the huge police resourcing and other governmental strategies that have been set up to tackle the global crisis.

The National Programme on Substance Abuse Deaths (np-SAD) report released in 2010 shows that there has been a decline in deaths occurring from stimulants such as cocaine, amphetamines and ecstasy type drugs.3 This may be due to the unavailability and/or low purity of such drugs leading abusers to find alternatives that are cheaper, easily available especially via the internet and those which produce the similar effects to illegal drugs. As a result the so called ‘legal highs’ in particular mephedrone (4-methylmethcathinone, meow meow/m-cat) gained increasing popularity on the drug scene during 2009-2010. The Advisory Council on the Misuse of Drugs (ACMD) reported a total of 18 cathinone-related deaths in England up until March 2010, however only seven of these actually tested positive for the presence of mephedrone. Nevertheless the harms associated with this drug and other cathinones were considered to be very high which eventually lead to a government ban being introduced on them in April 2010.3 (ref ACMD AS WELL, CHANGE ORDER ON REF LIST)

‘Legal highs’ are substances which produce similar effects to and are used like illegal recreational drugs.5 Some of the others which were reported in the np-SAD report included ketamine, piperazines and GBL (gammabutyrolactone) which imitate the effects of illegal drugs such as cocaine and ecstasy and were very popular in 2009 before the bans were introduced.3 The chemical structures of legal highs are not the same as the illicit drugs therefore they are not considered as illegal substances, consequently they are not controlled under the Misuse of Drugs Act 1971.6 Mephedrone like diethylpropion are derivatives of the alkaloid cathinone which is a naturally occurring stimulant extracted from the fresh leaves of the plant khat (catha edulis).7 In recent months changes have been made or are being made to control ‘legal highs’ as these potentially lethal drugs lack sufficient safety data. The fact that very little is known regarding the toxicity, potency and long term effects of such substances is one of the reasons why the ACMD have suggested a need for more basic research into the cathinones.7

1.2 Dopamine hypothesis and the brain reward pathway

There is substantial evidence suggesting that all drugs of abuse as well as natural rewards converge on a common brain circuit which was initially discovered in 1954 by highly influential animal studies conducted by Olds and Milner.14,15 They used intracranial self-stimulation paradigms in their classic animal experiments to demonstrate that direct electrical stimulation in specialised areas of the brain can be powerfully rewarding in rats which leads to positive reinforcement.16 The concept of the intracranial self-stimulation paradigms established the ability of the laboratory animals to operantly self administer stimulated pulses through implanted electrodes into specific brain regions via a lever press. In certain models the stimulation was so rewarding that animals would rather press the lever repeatedly for an extended period of time. This was to such an extent that they would rather starve and undergo extreme exhaustion than eat or drink.17Consequently researchers came to a conclusion that anatomically specialised reward systems do indeed exist in the brain which mediates a sense of well-being, and satisfaction.18

Furthermore studies by Wise19,20 have proposed a neurochemical basis for the pleasure centres and proposed the ‘dopamine hypothesis of reward’ which suggested that rewarding events occur as a consequence of activation of dopamine systems.19,20 From the four major dopaminergic pathways in the brain the most sensitive sites which are thought to serve as the final common neural pathway for mediating reward and reinforcement processes is the mesolimbic dopamine system (see figure 1).15,21,22 Therefore this pathway plays an important role in the control of motivation, emotion, motor control and reward-related behaviours such as the response to drugs of abuse. The structures involved in this pathway are connected via the medial forebrain bundle whereby the A10 dopaminergic neurons with a dopamine rich nucleus originates in the ventral tegmental area (VTA) of the midbrain, the neuron then projects to the limbic system through the nucleus accumbens (NAc), amygdala, hippocampus and the prefrontal cortex.

Figure 1: Rat brain illustrating the major structures involved in the reward pathway. The mesolimbic dopaminergic neurons originate in the VTA which sends ascending projections to the NAc and to the prefrontal cortex respectively. The mesolimbic dopamine system is strongly activated by emotions, memory, rewarding stimulus such as drugs of abuse and pleasure (figure adapted from …) 22

1.3 Drugs of abuse and the brain reward pathway

Drugs of abuse belong to diverse pharmacological groups targeting various receptor systems within the brain such as monoamine transporters/receptors, opioid receptors, cannabinoid receptors and nicotinic receptors (see figure 2).18 The brain reward system even though was initially found to mediate the actions of natural rewards such as food and drink, it is also stimulated by most drugs of abuse. Drugs of abuse mimic the pharmacological effects of natural rewards by increasing the dopaminergic transmission in the NAc.23 The effects of such drugs of abuse produces increases in extracellular concentration of dopamine which is initially rewarding to the user, this can then motivate and reinforce the user to perform the same reward-related behaviours.18 Repeated administration of the drug can lead to sensitisation whereby the behavioural effects are greater with each successive dose, the drug-taking process consequently becomes compulsive as the user becomes dependent on the drug. Eventually tolerance may develop whereby larger than normal doses of the drug are required to achieve the same effect. Physical and psychological dependence also manifests in drug addicts which necessitates them to continue taking the abusive drug to prevent the withdrawal and craving symptoms.(ref katzung bk)

Figure 2: Simplified presentation showing the actions of the major drugs of abuse on the VTA-NAc reward pathway. Psychostimulants directly increase dopaminergic transmission in the NAc. Cocaine and amphetamine activate dopamine release with the former binding to and inhibiting the DAT therefore preventing the removal of dopamine from the synaptic cleft.18 Amphetamine on the other hand stimulates dopamine release by binding to the transporter protein causing it to act in reverse and transporting the free dopamine out of the nerve terminal. It also interacts with synaptic vesicles to release free dopamine into the nerve terminal. This stimulant can also prevent dopamine degradation by binding to and inhibiting MAO.

Opiates and alcohol may inhibit GABA interneurons in the VTA which reduces the inhibitory action of GABA on dopaminergic neurons allowing the rapid firing of the dopaminergic neurons.23 Nicotine triggers reward directly through interaction with the nicotinic acetylcholine receptors on the VTA dopaminergic neurons which project to the NAc, and indirectly by stimulating the nicotinic cholinergic receptors on the glutamatergic nerve terminals.23 Cannabinoids mechanism may involve activation of the CB1 receptors on the NAc neurons. Phencyclidine (PCP) may act by blocking the excitatory glutamate input by inhibiting post synaptic NMDA glutamate receptors in the NAc.18 (Figure modified from Nestler.

1.4 Dopamine

Dopamine is a catecholamine neurotransmitter which is found in neurons of both the central and peripheral nervous system. Dopamine is the most abundant neurotransmitter in the mammalian brain and consequently plays a major role in numerous brain functions such as locomotor activity, cognition, motivation, reward and endocrine regulation.8,9 It is a monoamine transmitter synthesised from the amino acid tyrosine which subsequently undergoes two enzymatic reactions in order to produce dopmaine.8 Dopamine is considered to be a key neurotransmitter involved in reward-related processing and is particularly influenced by drugs of abuse as well as natural reinforcers such as foods and liquids. Furthermore, as drugs of abuse affect the dopaminergic neurons it also results in an alteration of many functions which dopamine is responsible for. Within the central nervous system (CNS) dopamine is found in the nigro-striatal, mesolimbic, mesocortical, and tuberofundibular brain systems;however it is the mesolimbic dopamine system which most drugs of abuse and natural rewards tend to stimulate.8

1.4.1 Dopamine release and reuptake mechanism

Dopamine is synthesised in the neurons and is stored in synaptic vesicles which are located in the nerve terminals. Dopamine can be released in two ways either through a calcium dependent mechanism or it may involve transporter mediated release which is calcium independent but sodium dependent. Dopamine release by exocytosis occurs when action potentials cause the release of the neurotransmitter from storage vesicles into the synaptic cleft via a calcium dependent mechanism.10As the nerve terminal undergoes depolarisation it triggers an influx of extracellular calcium across the plasma membrane through the voltage sensitive calcium channels. It is this rise in intracellular calcium which triggers an interaction between the proteins associated with both the vesicle and the presynaptic membrane, consequently leading to fusion of both of the membranes.10A pore is formed which releases the stored neurotransmitter. Dopamine release is also evoked by reverse-mode operation of the dopamine transporter (DAT). Amphetamine and its analogues can directly mediate the non-exocytotic release of dopamine from the presynaptic terminals by entering the neuron via the DAT. The drugs then interact with the dopamine containing synaptic vesicles causing the transfer of dopamine into the cytoplasm. As the cytoplasmic concentration of dopamine increases in the terminal, dopamine is expelled into the synapse through reverse transport of the DAT.add bk and to lis of ref

The free dopamine then diffuses across the synaptic cleft to bind to and stimulate post synaptic dopamine receptors. A signal is produced which causes either activation or inhibition of the post-synaptic neuron and alters cellular messenger cascades.11 There are five dopamine receptor subtypes which are responsible for mediating the various pharmacological actions of dopamine. The receptors possess a seven transmembrane domain and are categorised into either D1- like or D2- like depending on their pharmacological actions and signal transduction properties. The D1 and D2- like receptors are both found in the NAc and are responsible for mediating the actions of reward. The D1 and D5 receptor subtypes belong to the D1-like subfamily and are coupled to the Gs type G protein. These receptors are mainly located post synaptically and stimulate the activity of adenylyl cyclase. The D2, D3 and D4 receptors are D2- like which are located on both the post and pre synaptic neurons. They are coupled to the Gi/o type G protein therefore inhibiting adenylate cyclase activity. (ref c missale Daniela valone,)There are presynaptic D2/D3 receptors which also function as autoreceptors and are responsible for modulating and monitoring the release of dopamine. Consequently they prevent dopamine transmission by decreasing dopamine synthesis and release. Ref bk 1)

However the action of dopamine on the post synaptic receptors and the subsequent dopaminergic signals produced are terminated when the neurotransmitters are removed from the receptors and synaptic cleft. Therefore extracellular dopamine levels and the resulting dopamine neurotransmission is regulated by neurotransmitter transport systems such as the DAT. This carrier protein is responsible for the inactivation of dopamine signalling as it reuptakes the released dopamine from the extracellular space back into the presynaptic neuron where the dopamine can be stored in vesicles for future use.10 The DAT is a plasma membrane bound glycoprotein comprising of 619 amino acids with specific structural features including twelve trans-membranes along with N- and C- termini which are located in the cytoplasm.10,12 It is also a member of the Na?/Cl – dependent co transporters which uses energy generated from across the plasma membrane by the Na+/K+ -ATPase to co-transport two sodium ions, one chloride ion with each dopamine molecule from the extracellular space into the cytosolic compartment of the dopaminergic neuron.12

Another carrier protein which is responsible for the translocation of monoamines is the H+- dependent vesicular monoamine transporter (VMAT).There are two isoforms of VMAT, however it is the VMAT2 which is highly prevalent in the CNS. After the dopamine molecules re-enter the neuron, the VMAT2 which is driven by the proton electrochemical gradient is responsible for transporting the dopamine molecule from the cytoplasm into synaptic vesicles for storage and subsequent release.12, 13 Any dopamine that is not recycled undergoes degradation either whilst inside the dopaminergic neuron or when in the synapse. This occurs by both the enzymes, monoamine oxidase (MAO) and catechol-o-methyltransferase (COMT) to produce the end metabolite homovanillic acid (HVA).10

1.5 Neurotoxic effects of stimulant drugs

The Interagency Committee on Neurotoxicology has defined neurotoxicity as reversible or irreversible adverse effects on the structure or function of the nervous system by a biological, chemical or physical agent.24 Drugs of abuse such as amphetamines, methamphetamine (METH), methylenedioxymethamphetamine (MDMA) and cocaine can directly or indirectly cause CNS toxicity through many mechanisms and there is a vast amount of published data which is consistent with the proposed mechanisms of CNS toxicity.24-33 The neurotoxic potential of amphetamine and its analogues can be evidently seen by animal studies whereby there is long term damage to the CNS axons and terminals of monoamine neurons after administering high doses of stimulants. This neurotoxicity is manifested by reductions in brain markers as well as morphological changes of the dopamine and serotonin axons and/or terminals in the striatum. Furthermore depletions of the neurotransmitters themselves, along with their respective metabolites, biosynthetic enzymes and transporters is also detected.23,24 (add he book by lew

In an earlier study, rhesus monkeys were injected with increasing doses of METH for three to six months. A cumulative daily dose between 12.5-25mg/kg was administered 8 times a day, and it was found only 30% of the normal level of dopamine was detected in the caudate nucleus.ref bk lew, Other studies have also shown a greater dopamine loss in the striatum when compared to other dopamine rich areas such as the NAc, hypothalamus, and prefrontal cortex.ref ricaurte, wagmer, This was evidently seen when METH was administered at 15mg/kg every six hours for 5 doses. Levels of tyrosine hydroxylase and dopamine in the neostriatum were significantly reduced 36 hours after the last dose and 30 days after METH administration. However the short and long term effects of the tyrosine hydroxylase activity and subsequent dopamine levels only slightly changed in the NAc region.ref morgan gibb,aaps The toxic effects of METH have also been detected in serotonergic nerve terminals whereby various regions of the brain including the striatum, hippocampus and prefrontal cortex are affected which is not seen with the dopaminergic neurons. ref ABC, addictice reviews2 bk Another amphetamine analogue, MDMA has been shown to be more neurotoxic to serotonergic than dopaminergic terminals. After 10mg/kg was administered every 2 hours for 7days there was a 50% loss of serotonin content is the rat striatal tissue when compared to control whereas the dopamine content was minimally affected by MDMA.ref aap

The degeneration of the axon terminals has also been studied using a specific silver staining which was found to increase after METH administration therefore suggesting dopaminergic nerve terminal degeneration in the neostriatium and NAc which does support the above evidence with regards to reduced dopamine content in the striatum.29,30 In conclusion there is substantial evidence that amphetamine analogues induce neurotoxicity to dopamine and serotonin nerve terminals which is indicated by the loss of neurotransmitter content, enzyme transporters however when such effects are collectively seen, only then can it be strong suggested that the drug does induce CNS toxicity. (ref bk lew,aap)

Some of the cellular and molecular mechanisms in which psychostimulants induce both acute and chronic neurotoxic effects include excitotoxicity, oxidative stress and mitochondrial dysfunction, leading to cell death through the production of reactive species.26 Amphetamine and their derivatives induce dopamine release from the storage vesicles as well as increasing the levels of extracellular dopamine via reversal of the DAT.26,32 Furthermore, after displacing dopamine from the dopaminergic nerve cell, oxidative stress is mediated through enzymatic and non-enzymatic oxidation of dopamine which leads to an overproduction of highly toxic metabolites. Dopmamine is metabolised by MAO into DOPAC (dihydroxyphenylacetic acid) and H2O2 (hydrogen peroxide). The dopamine can also be oxidised by molecular oxygen via auto-oxidation to further produce reactive oxygen species (ROS) such as superoxide and peroxynitrite.24,26,32

Activation of the NMDA (N-Methyl-D-aspartate) receptors in response to rises in dopamine and the subsequent extracellular excitatory amino acid glutamate concentration causes an influx of calcium ions which consequently increases activation of NOS (nitric oxide synthase) therefore producing reactive oxygen and nitrogen species (RONS) such as peroxynitrite. Increased levels of reactive species can subsequently cause neuronal cell death due to oxidation of important cellular macromolecules such as phospholipids, proteins and nucleic acids.26,32

Mitochondrial dysfunction is another pathway which occurs through disruption of the electrochemical gradient established by the mitochondrial electron transport chain.26 Amphetamine and its derivatives are highly lipophilic cationic compounds therefore they easily enter the mitochondria where they raise the pH and disrupt the mitochondrial membrane potential causing apoptotic cell death. METH induced glutamate release and the subsequent rise in calcium in the mitochondria allows the mitochondrial permeability transition pore (PTP) to open and release calcium, this depletes ATP (adenosine triphosphate) reserves causing the mitochondrial rupture and necrotic cell death mainly through caspase-3.26 Evidence of mitochondrial dysfunction is apparent from the animal studies which have shown striatal ATP depletion in mice treated with methamphetamine.32 Reversible neurotoxic effects have also been detected, whereby inhibition of the cytochrome oxidase activity in the substantia nigra (SN), NAc and striatum was reversed in rats within 24 hours of receiving treatment of methamphetamine or MDMA.32

1.6 Cathinone

Cathinone (2-amino-1-phenyl propanone) is the main psychoactive alkaloid isolated from the fresh leaves of the plant catha edulis, which is more commonly known as ‘khat’. This herb has been grown in East Africa and the Arabian Peninsula for centuries where it is mainly chewed as a recreational and socialising drug due to its stimulatory actions.33 Cathinones are considered to be ‘amphetamine-like’ as their pharmacological and chemical properties closely resemble that of amphetamine. Similarly they also produce effects comparable to that of the prototype psychostimulant including sympathomimetic and CNS stimulation, therefore imitating the effects of amphetamine which include euphoria, alertness, increased energy and a sense of well-being.7

Amphetamines act on the monoaminergic system to increase the release of neurotransmitters including noradrenaline, serotonin and dopamine from the presynaptic storage vesicles.(ref from see beow)7As stated in the ACMD report; cathinones are also structurally very similar to amphetamine (see Figure 3). Therefore it has been proposed that cathinones and their derivatives also possess a similar mechanism of action to the psychostimulants and consequently may have a similar potential for abuse.

Experimental evidence has shown similar CNS effects between both cathinone and amphetamine.35-37 Numerous animal studies have suggested that both drugs show comparable behavioural effects such as producing the same degree of locomotor activity.35 Cathinone like amphetamine induces the release of catecholamines both centrally and peripherally.36,37 The dopamine released from CNS sites activates the dopaminergic pathways in the brain. It is evident that the stimulatory and rewarding effects such as hyperactivity and euphoria of cathinone occur via the same mechanism as that of amphetamine.

Despite cathinone being a controlled substance (Class C), certain derivatives of this compound like mephedrone, methedrone and methylone have been produced as ‘legal highs’ in order to avoid being classed under the Misuse of Drugs act 1971; however from April last year the entire ‘family’ of cathinone derivatives became controlled substances.

Figure 3: Chemical similarity between amphetamine and cathinone. Cathinone only differs from amphetamine due to the presence of ketone oxygen at the beta-carbon. Structural modifications have been made to the cathinone backbone in order to produce a range of compounds which are closely structurally related to cathinone and are known as the cathinone derivatives.

1.6.1 Cathinone and neurotoxicity

The structural and chemical similarity of cathinone and/or derivatives to amphetamine signifies that the pharmacological properties will also compare, and consequently research on the behavioural and psychological effects of these drugs suggest that the two compounds do possess related properties.34-37 However, when comparing the drugs in terms of toxicity potential, in particular neurotoxicity then there appears to be a major drawback as there is currently limited published data focusing on cathinones and their possible neurotoxic effects. On the other hand there is convincing literature confirming the neurotoxic pathways and mechanisms responsible for the amphetamines.(ref) Furthermore it may be that the cathinones are ‘amphetamine like’ in more ways than just the pharmacology and chemistry but also in terms of neurotoxicity. To date there is a lack of information regarding cathinone-induced neurotoxicity however it has been proposed that chronic administration of high dose cathinone (100mg/kg) does greatly induce a loss of dopaminergic neurons as is seen by the chronic administration of amphetamine.39 Furthermore there is insufficient literature available to support this study neither is there adequate data demonstrating the neurotoxic effects of cathinone at smaller doses. As a result it is currently difficult to make comparisons between cathinone and the amphetamines in terms of their neurotoxic potential and subsequent effects on the brain.

1.4 Diethylpropion

Diethylpropion (1 phenyl-2-diethylamine-1-propanone hydrochloride) also known as amfepramone is a cathinone derivative which acts centrally as an appetite suppressant and a mild CNS stimulant. Under the Misuse of Drugs Act 1971 diethylpropion is classified as Class C drug. According to the British National Formulary (BNF) it is no longer recommend for the treatment of obesity, however it is a very popular anorectic agent used in Brazil for the short term management of obesity.40,41 However reports of diethylpropion misuse in obese patients and amongst drug addicts has been reported in the past.41,42 Diethylpropion like cathinone is structurally similar to amphetamine (see figure 4) and acts as sympathomimetic agent whereby it enhances the release as well as inhibits the reuptake of catecholamines such as dopamine and noradrenaline. This therefore enables increasing concentration of catecholamines to act on post synaptic receptors.43 (add ref see at the end of ref list) However the potency of diethylpropion is not as great as the psychostimulant amphetamine, this is evident from studies where some researchers state that d-amphetamine is approximately 10 times more potent than diethylpropion therefore despite being amphetamine-like, it does not have equivalent effects at similar doses to amphetamine.

Figure 4: Structural similarity between amphetamine and the cathinone derivative, diethlpropion.

The effects of psychomotor stimulants on humans can include increased alertness, blood pressure, heart rate, induction of euphoria and suppression of hunger. Stimulants have been tested on laboratory animals and many studies have shown altered behavioural effects which cause animals to become restless and demonstrate increased behavioural and motor activity. Subsequently they elicit reinforcing behaviours and self administration all of which is largely dependent on increasing concentrations of dopamine in the mesolimbic system as hypothesised by Wise et al.19,20

There has been a vast amount of data on the behavioural effects of the prototypical stimulant agent amphetamine, however at present; the same cannot be said for diethylpropion. Despite there not being a lot of publications focusing on diethylpropion there are a few studies which have looked into the neurochemical and behavioural effects in animals. In one of the earlier studies45 varying concentrations of diethylpropion at 0, 10, 20, 40mg/kg was administered to rats for 36 days to determine whether diethylpropion produced typical psychomotor stimulant effects such as conditioned place preference.45 The conditioned place preference procedure is classically used to test any drug seeking behaviour in laboratory animals, whereby the animals learn to associate environmental stimuli with a positive or negative reward. The results suggested that only low dose diethylpropion at 10mg/kg resulted in such effects which was similar to that of the low dose amphetamine. The 20 and 40mg/kg diethylpropion did not show conditioned place preference; neither did it enhance motor-stimulant response with repeated exposure to the drug.45 Another study using the conditioned place preference protocol supports the finding that the stimulant like effects does occur with diethylpropion however in this study 10, 15, and 20mg/kg was tested but it was found that only 15mg/kg produced significant place preference in the animals.43

In a recent study a high dose of 40mg/kg and a low dose of 5mg/kg diethylpropion was administered to rats both acutely (5 minutes) and chronically (15 days) and the results did propose diethylpropion to be amphetamine-like. Despite the fact that only the acute treatment at low dose increased dopamine release it did not however show any effects on rat locomotor activity. This was only observable when rats were treated with a higher dose of 40mg/kg for 5 minutes. The results support the above study whereby it shows that chronic administration of diethylpropion at 40mg/kg does not increase locomotor stimulation.

Further behavioural studies have been conducted using diethylpropion which have looked into the effects of even lower doses of diethylpropion at 0, 1, 2.5 and 5mg/kg. This study aimed to investigate whether pre-exposure to the drug would sensitise rats to the motor stimulant effects of diethylpropion and induce conditioned place preference.41 It was found that 2.5 and 5mg/kg diethylpropion did enhance the motor activity as well as inducing conditioned place preference, though sensitisation was only observed with the motor effects.41 As with previous research diethylpropion has demonstrated psychostimulant characteristics and rewarding behaviour, however it is evident that these behavioural effects are consistent when lower doses were used.

In vivo diethylpropion experiments converge on a common finding which shows that the drug acts like other psychomotor stimulants as shown by neurochemical and behavioural studies. One of the main mechanisms of action of psychostimulants such as amphetamine is that it acts as a releaser which involves binding to transporter proteins and inhibiting the neurotransmitter reuptake by reverse mode operation of the monoamine transporter. This consequently allows more dopamine to move into the extracellular space. However in vitro research has shown that diethylpropion is inactive at the monoamine transporters.46 The reason for the lack of affinity at the DAT is due to the fact that diethylpropion functions as a prodrug.46 Furthermore researchers have shown that after absorption from the gastrointestinal tract diethylpropion is metabolised into three metabolites of which N-ethylaminopropiophenone is the bioactive metabolite (see figure 5) which is responsible for mediating the amphetamine-like effects. 44,46 However the remaining two metabolites (1R,2S)- and (1S,2R)-(?)-N,N-diethylnorephedrine showed minimal activity at the transporters. It was also found the neuroactive substrate N-ethylaminopropiophenone was ten times more potent at the noradrenaline than at the dopamine transporter therefore suggesting a possibility that the psychostimulant properties of diethylpropion may be due increasing levels of noradrenaline.(add ref for the emailed article)

Figure 5: Chemical structure of N- ethylaminopropiophenone also known as ethcathinone the bioactive metabolite of the prodrug diethylpropion (left).

1.4.1 Diethylpropion and neurotoxicity

It is well documented that potent psychomotor stimulants such as amphetamine, methamphetamine and MDMA induce neurotoxicity to striatal dopamine and serotonin nerve terminals which is characterised by depletion of the corresponding neurotransmitter content in brain tissue. Further studies have also suggested a role for the presence of reactive species which can be indicated by the presence of lipid peroxidation indicating oxidative stress.24-33 In addition the tyrosine hydroxylase activity and the number of monoamine transporters are also considerably reduced which does not confirm but can suggest possible neurotoxic effects.24-33 Thus it may be expected that diethylpropion will also show similar mechanism of injury due to its structural and pharmacological properties being related to amphetamine and substituted amphetamine analogues.

At present there is insufficient experimental evidence investigating the neurotoxic potential of diethylpropion. However in the study previously mentioned by Reimer 45 a whole rat brain was studied after twelve injections of diethylpropion at concentrations of at 0, 10, 20, 40mg/kg when administered over 36 days.45 The results indicated that there was no significant difference between the levels of noradrenaline, dopamine, serotonin or the metabolites HVA, DOPAC and 5-Hydroxyindoleacetic acid when compared to the control levels.45 Consequently this study found diethylpropion not to possess neurotoxic effects on monoamine neurons.45

In comparison, a neuropsychological study whereby crack –cocaine users received diethylpropion doses of 25, 50 and 75mg/kg for 9-14 days did not show a difference in the cognitive performance between the placebo and medication group.47,48 However this study is flawed when attempting to produce supporting evidence for diethylpropion neurotoxicity as the neurotoxic effects if any may come into effect after the study has been completed. Also the standard neuropsychological cognitive tests may not be sensitive enough to pick up any potential neurotoxicity.

On the other hand there is supporting evidence for the existence of neurotoxic effects of diethylpropion occurring through excitotoxic and oxidation pathways.48 Animals treated with 5mg/kg DEP for 15 days showed marked changes in the levels of neuroactive amino acids in particular glutamate (glu) and aspartate (asp) in the hypothalamus, cortex and midbrain regions which was considerably higher 24 hours after of diethylpropion administration.48 Evidence for oxidative stress was also confirmed by the increased rates of lipid peroxidation which occurs as a result of the formation ROS and RONS reacting with lipids.48 However the data present is not enough to support the notion that diethylpropion shares similar mechanisms of neurotoxicity as amphetamine and related just because they share chemical and pharmacological properties.

1.5 Aims and objectives

The aim of this experiment is to investigate the neurochemical and neurotoxic effects of diethylpropion on rodent brain slices.

The objectives include:

To analytically measure evoked dopamine release and reuptake using fast-scan cyclic voltammetry (FSCV) in rodent brain slices.
To construct concentration-response curves for dopamine release and reuptake in response to diethylpropionin the NAc region of the brain.
To test the neurotoxic effect of diethylpropion at various concentrations in the NAc using the 2,3,5-triphenyltetrazolium chloride (TTC) staining technique.

2.1 Rats and dissection

Wistar rats were supplied by St George’s University of London. They were caged and bred in a controlled environment. Only male rats aged between 7 – 9 weeks old (early adults) were used for the purpose of this experiment. On days of experimentation the rats were taken out from their cages and bought into the dissection room just before the dissection process begun.

2.1.1 Dissection process

The dissection instruments were first prepared in the laboratory. They consisted of the following:

a)Surgical scissors

b)Razor blades




f) Petri dish


h)Filter paper

i) Container for the above mentioned equipment to be placed into

j) Ice bucket

k)2x small tubes containing ice-cold aCSF solution stored in the ice bucket

l) 2x bottles containing ice-cold aCSF solution stored in the ice bucket

Before entering the dissection room the necessary protective clothing i.e gown, disposable overshoes, gloves and caps was worn for health and safety precautions. The rat was bought into the dissection room and was instantly killed by cervical dislocation. Using the surgical scissors the head was separated from the rest of the body and a cut was made throughout the skin of the head so any skin and tissue was removed leaving the skull exposed. Rongeurs were used to break open the skull and small pieces of the skull were carefully removed using scissors until the superior portion of the brain was uncovered. The brain was washed with the ice-cold aCSF to clear the blood and to reduce the risk of any tissue damage. The meninges were also gently removed with the forceps. After all the bone around the brain was removed, the inferior section of the skull was detached from the optic nerves so the brain could easily be removed from the remaining part of the skull, ready to be block cut.

After removal of the brain, the block was placed on filter paper pre-soaked with aCSF, which was resting on top of the petri dish. The brain was then subsequently washed with pre-oxygenated ice-cold aCSF. The brain was block cut in order to remove the unwanted sections. Coronal sections were collected so the area of interest i.e the NAc was not affected in any way. The brain was slightly sliced using a scalpel from the posterior to anterior ends ensuring the right and left hemispheres were to some extent separated. Before being placed into a tube filled with ice-cold aCSF the brain was once again washed with ice-cold aCSF and then replaced back into the ice bucket, ready to be sliced.

2.1.2 Slicing

The brain slicing procedure involved the use of technical slicing equipment called the vibratome (see figure 6). The blade was firstly placed into the machine. The posterior end of the brain was affixed to the chuck of the vibratome using superglue and was orientated into the correct position. The vibratome bath was filled with ice-cold aCSF, the speed (4/10) and vibration (10/10) was checked before any tissue was sliced. The machine was dialled down in increments of 400µm until the striatum had been reached. The striatum is the region located near the forebrain which contains the caudate nucleus, putamen and NAc and that is the area of interest. The tissue was then sectioned into 400µm thick coronal slices. As both hemispheres were sliced together the first couple of slices may have been stuck together therefore required separation with the scalpel. The cut slices were sucked up using the pipette and were placed in one of the ice-cold aCSF tubes straight away which was then stored in the ice bucket. When the required amounts of slices were taken (approximately 10 slices) they were taken back to the laboratory.

Figure 6: model… vibroslice. The brain block was glued onto the chuck and the bath was filled with ice cold aCSF whilst being attached onto the stage ready for slicing to take place.

2.1.3 Slice saver

The brain slices were then transferred into the slice saver which consisted of a small tub filled with aCSF, two sieves, an airstone and a lid (see figure 7). The tube filled with brain slices was removed from the ice bucket and the pipette was used to suck up the slices which were then equally placed into both of the sieves. The aCSF in the slice saver was previously being kept oxygenated as 95% O2 and 5% CO2 was bubbled through the tube at room temperature. The brain slices were placed carefully to ensure they were not squashed together and remained oxygenated at all times. After all the slices were in, they remained incubated in the slice saver for at least 45 minutes before they could be used for experimentation. This allowed the slices to adjust to the new temperature and tissue recovery to take place. Whilst in the slice saver the slices remained covered with the lid at all times to prevent any oxygen loss.

Figure 7: Slice saver. The tub was filled with aCSF right to the top. The slices remained in the two sieves and were covered with the lid while being oxygenated with 95% O2 and 5% CO2 through the airstone.

2.2 Artificial cerebrospinal fluid

In order to maintain healthy slices, 5L of the aCSF was made freshly on the days of experimentation with the specified salts mentioned (see table 1). These salts were ordered from Sigma Aldrich. Firstly a 5L conical flask was filled with 3L of de-ionised water. The individual salts were then measured using weighing boats, electronic scales and a range of different sized spatulas. To ensure all of the salts except from calcium chloride (CaCl2) were dissolved in the de-ionised water, the flask was thoroughly mixed. The 5L flask was covered with parafilm and the dissolved salts were then bubbled moderately with 95% O2 and 5% CO2 for approximately 20 minutes. The CaCl2 which measured previously was then dissolved in 500ml of de-ionised water and covered with parafilm. After main salts had been bubbled for 20 minutes the CaCl2 solution was poured in the 5L flask slowly and was shaken thoroughly then checked to see for any signs of precipitation due to the possible formation of calcium salts. If the solution remained clear then additional de-ionised water was added up to the 5L mark. The resulting aCSF remained bubbling in the 5L flask for at least 45 minutes. Some of the aCSF was then was poured into the slice saver and was bubbled simultaneously for approximately 30 minutes. When the experimental procedures finished at the end of the day the remaining aCSF was poured into a 500ml conical flask and covered with parafilm and was to be stored in the fridge until the next experimental day. On the following day, the stored aCSF was used to fill the two tubes and bottles for the dissection process. They were stored in the freezer for 20 minutes before dissection.

Table 1: Concentration of all reagents used in the making of aCSF

2.3Drugs and chemicals

The drug that was used for the purpose of this experiment was diethylpropion. The drug was ordered from Sigma Aldrich. Dilute hydrochloric acid (pH2) was also purchased from Sigma Aldrich in order to decontaminate the bath and system once weekly.

A stock solution of DEP was made first. A small glass bottle or plastic tube was placed on the balance, after tearing the balance approximately 3-5mg of DEP was measured into the bottle/tube. Depending on the amount of powder weighed the resulting amount of fluid was calculated and the DEP solution was made to 0.01M.

The following is the general type of calculation which was used to work out the required amount of de-ionised water for the DEP stock solution:

– Molecular weight (MW) of DEP: 242g

–Weight of DEP measured: 5mg

– 242g in 1L = 1M

– 242mg in 1ml = 1M

– 1mg in 1ml = 1/242M

–5mg in 1ml = 5/242M = 0.0207M

–5mg in 2.07ml = 0.01M

This stock solution was then thoroughly mixed, then used to make the various concentration of DEP (see table 2).

Table 2: Amount of stock DEP and de-ionised water required to make up drug concentrations.

2.4 Experimentation

2.4.1 Fast scan cyclic voltammetry (FSCV)

FSCV is the electroanalytical technique which was used to detect changes in extracellular concentrations of monoamines. Dopamine can be detected as it possesses voltage dependent redox properties. This method employs a three electrode system consisting of a carbon fibre working electrode, the reference electrode (silver/silver chloride) and an auxillary electrode (stainless steel wire). The Miller voltammeter applies a triangular voltage waveform between the working and reference electrode which scans between -1.0 and +1.4 V and back repeatedly at a scan rate of 480 V/s. The auxillary electrode only acts to balance the current at the carbon electrode.(ref) As the scanning potential occurs at such high rates, a large background current is produced due to the charged species re-arranging themselves around the electrode. During the positive voltage, when the dopamine molecules are present in solution they undergo oxidation and form dopamine-ortho-quinone and two electrons are donated. When the potential is returned back to -1.0V, the dopamine-ortho-quinone is reduced back to dopamine by accepting two electrons. The transfer of electrons between the oxidation and reduction process produces a faradaic current which also adds to the background current. However, by subtracting the background current from the DA signal the chemical changes of only dopamine can be visually detected on the oscilloscope owing to the presence of an oxidation peak during the first phase and the reduction peak is also evident when dopamine-ortho-quinone is reduced in the second phase.(ref)

2.4.2 Carbon fibre microelectrodes

Carbon fibres (Goodfellow Cambridge) were used for the working electrode which served to detect dopamine. The carbon fibres were 7µM thick. Many fibres were cut to a general length of 4-5 inches. Under the microscope one carbon fibre was selected from the collection of fibres enclosed within the sheet of paper. After ensuring the carbon fibre was long enough to fit in the borosilicate glass capillary, one end of the blank glass capillary tube was attached to the vacuum via the plastic tubing. The vacuum was switched on after making sure the glass capillary was firmly secured within the vacuum tube. The carbon fibre was then sucked into the glass capillary, however due to the suction pressure and the risk of the whole fibre being sucked into the vacuum the other end of the carbon fibre was being held down at all times. The glass capillary tube was then removed from the vacuum tubing and the vacuum was turned off.

The capillary with the carbon fibre inside was next inspected under the microscope (x10 or x20) to ensure that only a single carbon fibre was sucked in and that the length of the fibre was long and filled at least two thirds of the tube which was necessary in order to make a good electrical connection. The capillary was then ‘pulled’ to form a tip on one end of the tube using the microelectrode puller. It was important to see if there were any cracks in the fibre or glass capillary otherwise that would result in a poor connection. Also the point at which the glass capillary and carbon fibre joined together was checked to ensure it was at an acceptable level as a good attachment would reduce the risk of potential electrical noise. This was followed by cutting the carbon fibre using a scalpel so the exposed tip was approximately 50µm. After trimming the carbon fibre microelectrode, it was placed in the micromanipulator ready to be lowered into the bath.

2.4.3Apparatus set up

The brain slice was placed in the recording chamber (figure) with a pipette and a slice restrainy was placed on top of it to keep it in place and stop it from moving around.

2.4.4 Calibration

The electrodes were calibrated in aCSF, which was the same solution that the brain slice recordings were taking place in along with a known concentration of dopamine.

The equipment was firstly switched on:

– Micro-3 (A-D) converter

– Computer and spike 2 programme

– Vaccum

– Water bath

– Miller voltammetric analyser

– Oscilloscope

The signal was sampled at approximately 700Mv. The carbon fibre microelectrode was then lowered via the micromanipulator and placed into the bath. The other electrodes were all connected to the head stage. The aCSF was then put through the tubes and bath, and the flow rate was measured to check approximately 1.5ml/min was running through the tube. Whilst the aCSF was running through the system a stock solution of dopamine was made up to 0.01M using dopamine hydrochloride (MW: 189.64g/mol) as well as the calculation mentioned previously in 2.3. This solution was kept on ice and covered with foil as dopamine is light sensitive and is easily oxidised in air. When the electrode signal was stable, dopamine solution was added at 10– 5 M. This was achieved by diluting 100µl of the stock dopamine solution to 100ml of aCSF which produced a 10µM dopamine solution. The current flowing through the working electrode was checked on the oscilloscope. The voltammeter monitored changes in the dopamine signal. The oxidation peak produced by dopamine was detected by subtracting the original background signal from the dopamine signal which then showed the resulting oxidation and reduction peaks. If the voltammeter was not measuring at the correct potential then it was changed. The voltage difference of the dopamine peak was measured on the computer using the spike-2 programme and the dopamine reuptake was also measured from the exponential decay.

2.4.5 Brains slice testing

The bath, tubes and slice saver were first washed with dilute hydrochloric acid to kill any microbes and to wash away any drug from the previous experiments as most of the drugs are soluble in acid. The acid wash was performed at least once a week. The dilute acid (pH2) was run through each tube for approximately 10 minutes in each of the two tubes. De-ionised water was then put through the same apparatus and the pH was checked using the universal indicator paper to see if any acid still remained which would be evident if it turned red. The flow rate was also measured and maintained to 1.5ml/min. The aCSF was then prepared as mentioned in 2.2. The water bath was switched on which had a preset temperature of approximately 36°C, this aimed to heat the recording chamber so it was maintained at 32°C. Once the aCSF had been bubbling in the 5L flask for approximately 30 minutes it was poured into the slice saver and filled right to the top. The de-ionised water was turned off and some of the aCSF was separated into a 500ml conical flask and covered with parafilm, this was then bubbled through the tubes and into the bath. Whilst the aCSF was flowing through the system rat dissection and slicing took place as mentioned in 2.1.2 and 2.1.3. The temperature of the bath was also taken. The brain slices were transferred in to the slice saver (see 2.1.3.)The vacuum was switched off after 30 minutes of bubbling of the aCSF in the slice saver. One slice was taken out using the pipette and was submerged into the recording chamber. Under the microscope and lamp, the brain slice was positioned on the mesh in the bath, the bipolar stimulating electrode and the carbon fibre electrode which were held in the micromanipulators were released from the magnetic base and the stimulating electrode was first lowered 100µm into the slice. The carbon fibre electrode was also lowered by the same amount and positioned in between the two stimulating electrodes in the NAc region. The vacuum was switched back on and the brain slice was then perfused with aCSF at 1.5ml/min for 45 minutes to allow time for equilibration before any stimulation begun. The flow rate was measured during this time and if was too fast or slow it was adjusted accordingly using the variable clamp which was attached to the tube. Before the slice was disposed off it was identified using the brain atlas.

2.4.6 Electrical stimulation

A bipolar stimulating electrode was used for the electrical stimulations. Two tungsten microelectrodes were joined together and separated by a distance of 300µm. The stimulating electrodes were insulated apart from the tips of the electrodes in order to allow a current to pass. After 45 minutes of equilibration of the brain in the recording chamber the tips of the electrode were checked for any bubbles. The isolated pulse stimulator was used to evoke dopamine release from the brain slices every five minutes. The stimulatory parameters were checked and set to:

– Pulse number: 10 pulses

– Pulse frequency: 100Hz

– Pulse height: 10mA

– Pulse width: 1ms

– Pulse duration: 10ms

All the equipment mentioned in 2.4.4. was already switched on and a new file was started using the spike-2 programme on the computer. Before carrying out any experiments with the drug, the aCSF was allowed to run through the tubes and the first stimulation that was produced was ignored as it was counted as a pre-stimulation. A further three stimulations were produced every five minutes. The resulting dopamine peak and reuptake was measured for approximately 15 minutes. During this time the diethylpropion at a particular concentration was prepared from the stock solution (see section 2.3) which was bubbled and then covered with parafilm. When the results of the three stimulations were stable and consistent then the diethylpropion solution which had been previously prepared was put on and the aCSF tap closed. A syringe was used to pull the drug solution to help with the flow and the resulting flow rate was marked on the flask. The spike-2 programme was used to measure the dopamine peak and time constant, whereby the latter was measured from the exponential decay. After an hour of electrical stimulation with the drug on, the tap was closed and the aCSF tap was switched on to clean out the system.

2.5 TTC (2,3,5-triphenyltetrazolium chloride) Staining

It is evident from the literature that potent stimulants such as METH induces neurotoxic damage to the dopaminergic and serotonergic neurons and the possible mechanisms by which this occurs has been fully described in section 1.5. The pathways involved mainly consist of the production of reactive oxygen and nitrogen species through dopamine auto-oxidation, glutamate release and subsequently mitochondrial dysfunction. Cellular mitochondria are one of the most important organelles as they are responsible for the generation of ATP through the Kreb’s cycle and electron transport chain (ETC). As nerve cells are always in a state of high metabolic activity it is expected they will possess larger numbers of mitochondria in order to fulfil the neurones energy demands. Therefore dopaminergic neurons are highly sensitive to mitochondrial damage. TTC staining is a marker of mitochondrial dysfunction and cell health. It allows the macroscopic differentiation and evaluation of viable and infarcted tissue. TTC staining is a sensitive technique which shows the presence of active mitochondrial oxidative enzymes which is detected by a colour change. In healthy brain tissue the colourless tetrazolium salts in TTC react with mitochondrial oxidative enzymes to form a red formazan pigment resulting in red staining of the brain tissue. In neurotoxic tissue the mitochondrial oxidative enzymes are dysfunctional therefore the TTC does not reduce to its red derivative; subsequently the unhealthy areas of the brain stains a pale white as it lacks the enzymes with which the TTC normally reacts with.

2.5.1 TTC staining of brain slices

Brain slices which were sliced after the dissection and remained in the oxygenated in the slice saver were used for the TTC staining process. The following solutions were made up and placed in a small tube:

– Control (no diethylpropion, normal oxygen)

– Dilute hydrochloric acid

– Diethylpropion at various concentrations made up with aCSF

A pipette was used to place a brain slice in each of the tubes. The tubes were then placed in the water bath using duck tape and were incubated at 36°C for 60 minutes. The TTC solution was taken out of the fridge and added at 0.05% concentration (1 in 20 dilution). Separate pipettes were used to avoid contamination. After the TTC had been added, the tubes were placed back into the water bath and were incubated for a further 60 minutes at 36°C. Whilst the tubes were in the water bath a 1 in 3 dilution of 10% formaldehyde was made into a beaker. The formaldehyde acted as a preservative so prevented the tissue from degrading for a long time. The formaldehyde was added to the tubes using a syringe at room temperature for 30 minutes. Microscope slides were labelled with the concentration, drug name and date. Under the fume hood and when wearing gloves, the slices were taken out of the tubes using the pipette and placed onto the slides, any excess fluid was removed. They were then allowed to dry for 60 minutes. A small amount of histomount was added and the slides were left to dry for another 60 minutes. The slices were photographed before the coverslip was attached and were analysed using Image J software on the computer.

2.6 Statistical analysis

Statistical analyses were carried out by a one way analysis of variance (ANOVA). The data is presented as mean±SEM. The criterion of the significance was set at P<0.05. The statistical analysis was performed using sigma plot and the graphs were produced using GraphPad Prism. n = number of brain slices.


FSCV was used to measure the dopamine release and reuptake from the NAc region of the rat brain slice in response to four different concentrations of diethylpropion and control (figure 10 and 11). The dopamine release was measured by the change in peak height and time constant was defined by the exponential decay. The resulting values were then calculated as the percentage change from the baseline concentration where 100% was defined as the average from the first three stimulations.

Figure 10: Graphs showing the effect of diethylpropion (DEP) at 1, 3, 10, 100µM and control on dopamine release in NAc regions of rat brain slices. The arrow represents the administration time of diethylpropion at the end of the last baseline stimulation. Dopamine levels were measured every 5 minutes for the next 60 minutes. Data are mean ± (SEM) values from a total of 13 brain slices were n = 2 – 3 for each concentration and is expressed as a percentage change of the corresponding baseline value.

Dopamine levels were measured every 5 minutes for the next 60 minutes. Data are mean ± (SEM) values from a total of 13 brain slices were n = 2 – 3 for each concentration and is expressed as a percentage change of the corresponding baseline value.

Figure 11: Graphs showing the effect of diethylpropion (DEP) at 1, 3, 10, 100µM and control on dopamine time-constant in NAc regions of rat brain slices. The arrow represents the administration time of diethylpropion at the end of the last baseline stimulation. Dopamine levels were measured every 5 minutes for the next 60 minutes. Data are mean ± (SEM) values from a total of 13 brain slices were n = 2 – 3 for each concentration and is expressed as a percentage change of the corresponding baseline value.

Statistical analyses were performed on the averages of the last three stimulations of each brain slice. One-way ANOVA or Kruskal-Wallis one-way ANOVA on ranks was used to compare the means of diethylpropion (1, 3, 10, 100µM) and control. In both graphs (figure 12 and 13) the null hypothesis was accepted as there was no significant difference between the mean percentages of dopamine release and reuptake in all groups.

Figure 12: Summary of effect of diethylpropion (DEP) at 1, 3, 10, 100µM and control on dopamine release in the NAc regions of rat brain slices. The effect of diethylpropion on dopamine release was assessed by one-way ANOVA on the last three averages of each slice where n = 2 – 3 for each concentration. F (4, 12) = 3.290, P = 0.071. Diethylpropion at the various concentrations and control group did not show a statistical significant difference when comparing the means of stimulated percentage dopamine release (P > 0.05) Data shown are mean ± SEM values for a total of 13 brain slices.

Figure 13: Summary of effect of diethylpropion (DEP) at 1, 3, 10, 100µM and control of dopamine release in the NAc regions of rat brain slices. The effect of diethylpropion on dopamine time-constant was assessed by one-way ANOVA but failed, therefore the Kruskal-Wallis one-way ANOVA on ranks was performed on the last three averages of each slice where n = 2 – 3 for each concentration. H (4) = 7.308, P = 0.120. Diethylpropion at the various concentrations and control group did not show a statistical significant difference when comparing the means of percentage time-constant (P > 0.05) Data shown are mean ± SEM values for a total of 13 brain slices.

Comparison of amphetamine to diethylpropion

The neurotoxicity potential of diethylpropion was measured using the TTC staining technique. The viability of neuronal cells and cell health was determined by the presence active mitochondria whereby a change of stain colour from red to pale white would suggest an unhealthy brain slice. Image J software (National Institute of Health) was used to measure the loss of stain in terms of area (mm2) and mean density of the stain was also measured. Mean density was measured on a scale of 0-255 whereby the lower end of the scale indicated a denser stain and consequently a healthier slice. However a higher value signifies mitochondrial dysfunction resulting in a pale white colour. The coronal brain slices mixed with TTC solution was tested with diethylpropion at 10 and 100µM (figure 16, 17) and then compared to control (figure 18). The following results show the mean density of a total of three brain slices in both the caudate and NAc region (figure 15)


Diethylpropion is a low potency psychostimulant which also acts as an anorectic agent. It is a derivative of the cathinones which are considered to be ‘amphetamine-like’ therefore it has been hypothesised that diethylpropion has similar pharmacological and toxicological properties to the prototype psychostimulant. In the present study the direct effect of diethylpropion on dopamine release and time constant was evaluated using rat brain slices. FSCV was the method used for neurochemical detection and there are many advantages of using this particular method. One of the reasons this technique is commonly used in preference to others is because it is possible to measure fast changes of extracellular neurotransmitter on a subsecond timescale. Also several brain slices can be obtained from one animal all of which contain the specific areas of interest, consequently this reduces the risk of variation within the experiments and reduces the number of animals used. The small carbon fibre electrode makes it easier measure monoamine changes in a variety of anatomical regions of the brain.(ref 123)

The voltammetry results indicated that there was no significant dose-dependent effect on dopamine release in the NAc over the time-course of the experiment. From the graphs (figure 10) it is evident that after administration of diethylpropion (100µM) there was almost a 50% increase in dopamine release by the end of the experiment. The mean percentage dopamine release values for 3 and 10µM diethylpropion generally fell below the 1µM concentration (see figure 10) which is not what was expected. However the fact that only two brain slice experiments were conducted for the 3 and 10 µM in comparison to the other concentrations where n=3 could have explained why the values were lower than the expected mean percentages. The effect of diethylpropion on the time constant of dopamine was again shown to be most effective at 100µM whereby it increased the time constant by approximately 130% of the baseline (figure 11). A dose response curve could not be produced for dopamine release as the results were inconsistent and varied with each concentration also the maximal response could not be calculated. Subsequently a sigmoidal curve was not drawn and the EC50 could not be determined. This was one of the major limitations of the experiment, however if more experiments were carried out for each concentration using more brain slices per concentration or if another experiment was tested for the 3 and 10µM in order to complete the data set to n=3, then it may have possible to detect a concentration effect on time constant (figure 13). From looking at figure 13 it can be seen the percentage time-constant did slightly begin to show and may well have shown a dose dependent effect had more brain slices been tested. The S shaped curve was not seen in figure 12, as diethylpropion had a varied response to dopamine release at the different concentrations. It was shown that the 3 and 10µM once again produced a smaller increase in percentage dopamine release when compared to 1µM and it is hypothesised this may be a result of a lack of a complete data set for the two concentrations. Despite evident increases for 100µM diethylpropion, statistical analyses showed that at no concentration did diethylpropion induce a significant change in dopamine reuptake time or release. Due to limited time and the lengthy procedure of voltammetry it was not feasible to gather a complete data set for this study. However if the study was to be extended then a greater number of brain slices could be tested with the same parameters to detect if there was actually a significant difference. Also post-hoc testing for multiple comparisons will also be of benefit if a significance difference was found.

The findings from this study cannot be compared to other brain slice experiments as majority of the literature looking into diethylpropion focuses on the behavioural effects of the stimulant in live animals. However the results from behavioural studies do propose diethylpropion to possess amphetamine like properties as they show similar stimulant effects to amphetamine. Therefore it does suggest they do to some degree share similar pharmacological properties. It is proposed one of the mechanisms in which amphetamine primarily acts is by binding to and inhibiting neurotransmitter reuptake as well as promoting the reverse transport of neurotransmitters such as dopamine, noradrenaline and serotonin which increases their movement out of the nerve terminal and enhances interaction with the post synaptic receptors.

When comparing the effects of stimulated dopamine release using FSCV in response to amphetamine and diethylpropion it is evident that there is a marked increase of dopamine release and reuptake time with amphetamine when compared to diethylpropion at the same concentration. This is evident by the wider and prolonged triangular peak of the voltage vs time curve which shows that the time taken for dopamine reuptake from the extracellular space is longer which indicates that the stimulant is interacting with the monoamine transporter. The increase of amphetamine is most likely to be underestimated at higher concentrations due to the action of the autoreceptors which inhibit dopamine release via a negative feedback mechanism. The dopamine release and reuptake level for diethylpropion did not compare to amphetamine as already mentioned it is a low potency stimulant.

A possible reason for it not showing a similar degree of dopamine release and reuptake to amphetamine is that it functions as a prodrug consequently it is inactive at the monoamine transporter sites. Studies which have looked into the uptake and release effects of diethylpropion suggest that one of its metabolites i.e N-ethylaminopropiophenone is strongly potent at the noradrenaline transporter followed by dopamine then lastly serotonin. Therefore it was concluded that the amphetamine-like effects produced by diethylpropion which is evidently seen in behavioural studies may be due to this particular metabolite having a greater effect on the release of noradrenaline rather than dopamine. To test this hypothesis and to further this study it may be an idea to measure the effects of diethylpropion or its active metabolite on noradrenaline release and reuptake using FSCV as this neurotransmitter can also be oxidised at a low voltage. The results can then be compared to the effects of dopamine release and reuptake using the same stimulation parameters and concentrations.

As this study only looked into the effects of dopamine release and reuptake in the NAc, the results were only reflective of a specific region of the brain. Furthermore, if there was available time then the effects of diethylpropion could have also been tested in the caudate to see if there were any significant regional variations in neurotransmitter release and reuptake as there were brain specific regions showing greater or less neurotoxic effects when tested with TTC staining.

The results from the TTC staining did not show a dose-dependent loss of staining as it was hypothesised that with increasing concentrations of diethylpropion there would be a gradual rise in numbers of cell death owing to the loss of mitochondrial function. However the opposite effect was seen with diethylpropion whereby the higher concentration of 100µm even though it showed a larger area of staining on the brain slice it was not as dense then at the lower concentration which showed a greater density of ……. In order to make valid comparisons to the control it would be necessary to repeat the staining with more than just one brain slice per concentration. As a result statistical analyses could not be performed on the TTC staining results therefore it was not possible to determine whether diethylpropion did show markers of neurotoxic effects.

FSCV was only used to measure changes in monoamines in vitro from brain slice testing, however to get a complete understanding of how diethylpropion works in the brain it should also be supported with in vivo data whereby the same procedure should involve the administration of drugs in freely moving animals such as rats, mice and monkeys and correlate the neurochemical changes with behavioural changes. These experiments together with other neurochemical methods such as microdialysis will provide a greater understanding of the neurotransmitter release and reuptake systems in the brain after drug administration.


In conclusion the results suggest that diethylpropion does not significantly alter dopamine release or time constant. The results from the TTC staining was not sufficient enough to make suggestions as to whether or not it does possess neurotoxic effects like the amphetamines have been previously described to possess. As this was the first in vitro study measuring the effects of diethylpropion using FSCV on rat brain slices the results could not be compared to other studies. Diethylpropion is known to have similar pharmacological and chemical properties to amphetamine as demonstrated by behavioural experiments. In light of recent government reports and research there is a need for more basic research into this class of drugs in particularly the way it affects the neurotransmitter systems in the brain, especially as there is a potential role for alternative monoamines mediating the ‘amphetamine-like’ effects. It is important that research is continued into studying the effects of diethylpropion and to see if and to what extent it compares to other stimulants such as the amphetamines in terms of monoamine dynamics behavioural changes and toxicity. Recommendations for improvements to this study would be to repeat the experiments using a complete set of data and to increase the brain slice number for both FSCV and TTC staining in order to get more reliable results with which statistical analyses can be performed with. Further research into the effects of diethylpropion on noradrenaline release and reuptake would expand the study and help the understanding of the basic mechanisms of actions of this drug. The study could be modified to include the electrochemical testing of different regions of the brain rather than just focusing of the NAc and also to be measured in live animals and not just with the brain slices. This will hopefully expand the literature on diethylpropion and will fulfil the recommendation made by the ACMD in response to their report on the consideration of the cathinones.

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Free Essays

Sexual and Reproductive health needs of Sex workers in Tanzania


Around the world sex workers are defined as “female, male and transgender adults and young people who receive money or goods in exchange for sexual services, either regularly or occasionally, and who may or may not consciously define those activities as income-generating.”The term sex worker has gained popularity over prostitute because those involved feel that it is less stigmatizing and say that the reference to work better describes their experience.

According to UNAIDS,(2005) a sex worker is person who provides sex for money or goods and this may be occasionally or on regular basis. The groups involve female male adolescences and transgender adult, but they don’t exactly consider this act as earning money.

It estimated about 1995, 333 million cases of curable sexually transmitted diseases (STDs) occurred in the world, 65 millions of which were from Sub-Sahara Africa alone. WHO, (2007)

In Tanzania sex work is illegal under Tanzanian law. However, sex work is practiced openly in many areas across the country Due to lack of money Many women and children engage into this business due poverty which is caused by lack money???

Sex work in Tanzania including child trafficking is a major problem, especially in Zanzibar and Pemba child sex tourism is largely operated, and majority of them are infected by STI. Many of the children got involved into this sex work due to various problems for example after becoming orphans after their parents died from HIV/AIDS. ILO, (2001)

Majority of women and youths are the most affected groups due to being unstable economically, socially and cultural. Therefore, it is evidence that lack of money is one of the country determinants. Sex workers are categorized as a mobile population (sex workers) which is at high-risk due to their vulnerability to infectious diseases due to the nature of the work like plasticising sex without use of condom. NACP,(2007).

get tempted easier to exchange sex for money which put them into risk including their partners to acquire sexual transmitted infections including HIV/AIDS. More than 50% of the Tanzanians live below the poverty margin which forces them into sex exploitation.Sex workers usually has low access to health services including screening and treatment of HIV and AIDS. NACP, (2007).

Ford .N. et al, (1999), revealed that in sex worker industry there are different groups involved in this practice men who sell sex to other men and gender issue is not a problem to them.

This report is mainly going to look on Sexual and Reproductive Health needs of female sex workers. There are two types of sex workers direct sex worker and indirect sex worker. Direct Sex Worker is a person, male or female, selling sex as an occupation or main source of income.

Direct Sex Workers may be either street based or based in a brothel or other fixed location, whereby an Indirect Sex Worker is a person, male or female, working in the entertainment business, such as in bars, karaoke canters, beauty salons or massage parlours, who to increase their income also sell sex. It should be noted that not everyone working in these places sells sex.

1.1 Sexual and Reproductive Health needs of sex workers

Around the world sex workers are regarded as higher vulnerable groups with high prevalence (United Nations, 2003). In order to minimize the prevalence of STI, several steps measures needs to be enforced into this groups.

Education on sexuality-It includes comprehensive sexual education programs including community based health programs
Screening and Treatment of STIs-It involves the screening and treatment of STI for sex workers and community at high risk for various diseases like gonorrhoea Chlamydia including HIV/AIDS and HIP .Screening and treatment has being identified as the effective way for sexual and reproductive needs for female commercial sex workers in Tanzania . Steen, (2002.2003) in his study revealed that both presumptive for sex workers and community based STI treatment for whole communities at high risk, can reduce the risk of HIV transmission.
Family Planning Services–Ongoing and availability of Contraceptive and counselling services are vital to these groups. Moreover, types and how to comply with the pills is very essential as this will help to minimize the unwanted and unsafe abortions.
Delivery Services –It includes ANC and Delivery services -This type of service is essential for Sex workers due high number of pregnancies caused by unsafe sex. (Guttmacher Institute 1998).
Condom Use Services (programs). Availability of Condoms and their utilization among female sex workers in Tanzania is vital as many of sex workers are forced to perform unprotective sex by violent clients and the amount of money given.
Establishment of clear policy framework for sex work– It involves development of strategies , legislative changes and its implementation
Healthcare access –Fare/available access to healthcare services such drop in centre

In Tanzania there are severalReproductive and Sexual health policies that aims to improve and also address the needs of women such as National policy on HIV/AIDS National adolescence health policy but all these policies does not contain provision of sexual Reproductive Health for Female Sex Workers .

The reproductive and sexual health policies that exist within the Tanzanian health system aims to address the needs of women include; the national reproductive health strategy, national adolescent health policy and the national policy on HIV/AIDS. Furthermore, because sex work is illegal in Tanzania sex workers are outside the scope of national HIV/AIDS programmes. However, these policies have no provision for specialized Reproductive Health services for FSWs which is necessary to address the reproductive and sexual needs of Female sex workers.

Assessment of Unmet Needs.

Contraceptive services. Family planning helps to reduce the number of highly risk pregnancies that results in high level of maternal illness and death (Health Policy 2009). In every country, sex workers face many of the same dangers and rights problems.

Despite legal restriction and the medical risks associated with clandestine procedure, Tanzanian women obtain abortion from a wide range of providers, including doctors at private clinics, organisation when vacuum aspiration is not available. Women in rural areas have less much access to treatment for abortion complications than do women in urban settings.

Private sector facilities handle more than half of post abortion care cases despite the fact that they charge patients about three times more than public facilities do.

In East Africa in 2003, almost one in five maternal deaths were due to unsafe abortion .Even more common are long term health problem social stigma and infertility. Abortions performed by a skilled person are much more expensive than riskier procedure performed by unskilled provider’s .Therefore it is likely

In Tanzania the need for safe abortion is very important issue especially among FSWs as some of them due the lack of the clear abortion service .From my own experience when FSWs they get pregnant they end up killing their born infants and wrap them in a bin liner or any plastics bags and throw them along the road.


2.1 STI Screening

The sexual and reproductive health needs of sex workers have been neglected both in research and public health interventions, like Millennium Development Goals (MDGs) which have almost exclusively focused on STI/HIV prevention. Chacham et al, (2007), revealed that the reasons among this issue are due to the condemnation, stigma and ambiguous legal status of sex work

Majority of Female Commercial Sex Workers (FCSW) often have high rate of STIs due to unprotective sex activities and access to effective STI treatment. Frequent unprotective sexual exposure put sex workers, their clients and other partners all at high risk of acquiring HIV/STIs Steen, (2003).

Reducing the prevalence of Sexual Transmitted infection (STIs) would greatly reduce the risk of transmission of HIV.


According to (UNAIDS 2000), It is very essential to involve sex workers in policy and programme development and implementation as part of the overall empowerment –building process and for greater programme effectiveness.

Many 100% condom use programs are focused on the experience of Thailand. In the 1990s, Thailand conducted a massive programme on control of HIV which showed a significant drop on visits to commercial sex workers by half, utilization of condom Increased, the prevalence of STDs fell dramatically, and achieved substantial reductions in new HIV infections. Avert (2007).

Similar programs were implemented successful in Cambodia, Laos, Mongolia and Philippines whereby, in most of these programs local or national authorities, including police, were required to use condoms in every sex act.

Use of Contraceptive

A study conducted by Delvaux, (2003) found that huge number of female sex workers had limited knowledge of how to use contraceptive pills, condoms and syringes for those who are IV drug users. In Tanzania the use of contraceptive pills among majority of sex workers was very limited which increased the percentage of safe abortion due to poor awareness.

Globally condom use alone is considered problematic by family planning promotion due to fear of birth rate increase or abortion and this happens during the first year of condom use when more accidents are likely to happen (Berer, 1997) .

Another problem is the wide spread provision of non-barrier contraceptive for sex workers might lead to reduction in their use of condom (Delvaux, 2003). Another problem is the wide spread provision of non-barrier contraceptive for sex workers might lead to reduction in their use of condom (Delvaux, 2003).

Healthcare access – Some of the sex workers in Tanzania fear to use Public healthcare facilities due to discrimination and stigma from healthcare workers, other service users, lack of money and insurance due to poverty.

Many sex workers in East Africa lack access to the insurance system because of their profession. Some are trafficked women from rural area who do not have identification or permanent residence documents they need to get health care. Landipo, (2005) revealed that high attendace to private health facilities like Pharmacies and medical stores; to purchase contraceptive pills contributes to low attendance to public facilities, which can results to poor compliance of the contraceptive pill among sex workers


Based on findings above, the following recommendations are being made to the national centre for HIV/AIDS and STIs:

Proposed programme components:

Sensitise policy makers to enact laws which lead to tolerance of FSWs. This will be a cornerstone to destigmatisation and allow these women to enjoy a greater degree of human rights. It will also allow the government to set aside specific funding and to solicit ate further input from the donor community.
Mobilization of FSWs for a systematic STD/HIV/AIDS prevention course that includes participatory education, prevention, and positive living when infected and peer counselling.
The condoms should be free or at a price the FSWs can afford. Proper use of condom is crucial in the absence of a vaccine or cure. It is also important for FSWs to know where to get condoms for example. Clinics, chemists and peer educators also storage and disposal methods should be covered in education.
Although condom is the prevention method of choice, it is not 100% efficient due to breakage or slipping, meaning that some FSWs will still get infected. Therefore prompt and proper management of STDs which includes counselling, condom use, contact tracing and compliance is vital for prevention of HIV transmission.
Proper use contraceptive pills needed in order to meet compliance and its irrational use.
The FSWs should be trained and offered opportunities for alternative income generating activities. This is because according to the writer’s experience, well over 90% of women in Africa are in commercial sex due to poverty and lack of an alternative. The low economic status also interferes with condom negotiation and therefore should be addressed.


UNAIDS Guidance Notes on HIV and Sex Work, 2009, p. 2.

http// bibliography

UNAIDS Inter-agency Task Team on Young People (2006) Section 2. (reference above) bibliography

Department of Reproductive Health and Research (2004) Part 2 (reference above) bibliography

Sexual and Reproductive Health needs of sex Workers: Two feminist Projects in Brazil. Bibliography


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Ngugi E.N., Staugard F., Gallachi A., Njoroge M., Waweru A.L Social Economic Empowers Commercial Sex Workers to Reduce Reported Attack Rate of STDs. Xth International Conference on AIDS and STD in Africa, Abidjan, December 1997. (C. 290).

DITTMORE, M. 2008. Punishing Sex Workers Won’t Curb HIV/AIDS, Says Ban-Ki Moon. 24 June. RH reality check. [online]. [Accessed 18 January 2011]. Available from:

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The Open Tropical Medicine Journal, 2 2009 [online]. [Accessed 07 Feb. 11], pp 27-38 Stadler J, Delaney S. The ‘healthy brothel’: The context of clinical services for sex workers in Hill brow, South Africa. Cult Health Sex 2006; 8(5): 451-63.

Ford N, Koetsawang S. The socio-cultural context of the transmission of HIV in Thailand. Soc Sci Med 1991; 33(4): 405-14.Wojcicki J, Malala J.

Condom use, power and HIV/AIDS risk: sex workers bargain for survival in Hillbrow/Joubert/Brea, Johannesburg.Soc Sci Med 2001; 53: 99-121.

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GEETANJALI.G, 2002.Unmet needs: Reproductive Health Needs, Sex Work and Sex Workers .Social Scientist.30 (5/6) pp.79-102

Free Essays

Occupational Health Psychology (OHP) is concerned with the application of psychology in other to improve the quality of working life to protecting and promoting the safety , health and well being of workers(NIOSH).


OccupationalHealth Psychology (OHP) is concerned with the application of psychology inother toimprove thequality ofworking life to protecting and promoting thesafety , health and well beingofworkers(NIOSH). Protection and promotion are geared towards interventionsto reducehazards at work and to equip individual workers with knowledge and resources toimprove theirhealth(CDC, 2010).

Theterm OHP wasfirst mentionedby FriedrichEngels in1845 and in1987 ashe wroteon “theconditions of workingclass in England”. Karl Marx (1867 & 1999) also usedit inwriting “the horrificways whichcapitalismtookadvantageofworkers in Das Kapital”. Karaserk (1979) castigatedTaylors approach on how jobmustbe done havealso made contributionstoOHP.

OHPrequires aninterdisciplinaryapproach(Maclean, Plotnikoff & Moyer, 2002). Examples arepublic health, preventative medicine, industrialengineering, etc. The primary focus of OHP is the prevention ofillness andinjurybycreating safe andhealthyworking environment (Quick et al.,1979, Saiter, Hurrel, Fox, Tetrick and Barling , 1999). Themajorchallenge in promoting occupationalhealthischangingnature of work and workforce (Quick & Tetrick, 2002). Peoples exposure to workenvironment may bevery dynamic making it verydifficultfrom anepidemiological perspective to identify the sources ofill health (Berkman & Kowachi, 2000).


Amyriadofbenefits toboth employersandemployees can be realised from OHP. The Health and Safety atworkAct (1974) says,“it shall be theduty of every employer to ensure the health at work ofall employees. Employers have to uphold a duty of care and to ensureas far asisreasonable andpracticable, the health, safety and welfare of all their employees. Theemployermustnot act or conducthimself in a waythat will causeinjury to theemployee”.(HSE, 1995).

TheHealthand Safety Executive (HSE) in the United Kingdom hasbrought to bear ManagementStandards in OHP to helpbring downthelevel ofworkrelated stressbythe introduction ofthecompetency framework (CIPD, 2007). Stress is defined as a particular relationship between the person and environmentthatisappraisedby the person astaxingor exceedinghis or herresources and endangeringhisor her well being (Lazarus and Folkman, 1984). Management Standards is defined as characteristics or culture of an organisation where the risk from work related stress are being effectively managed and controlled (Kerr et al.,2009). In theManagement Standards, six potential variables(demand, control, support, relationships, role and change) ifnotorganisedappropriately could lead to poor health and well being, decreased productivity andincreased sickness and absence (Cousins et al., 2004 & Mackay et al., 2004) . Theyalsohave the potential of impacting on workersdisregarding the type and size of the organisation (Mackay et al., 2004).

OHP, emphasise on the importance ofemployee control and participation. The SwedishWork Environment Act(1978) has made psychosocial and psychological stands. The Swedish Act ofCo-Determination(1977) give workers a mouth piece on job design, methods of production, working environment and organisational decision making (Gardell & Johansson, 1981).

OHP opens thegatewayfor employers todevelop stresspolicies which aregeared towards protecting health, safety and welfare ofemployees. In the UK, the HSE Act of1974 allowsorganisations to take note of all stressors andconduct risk assessment toquash stress and controlrisksfrom stress, consultations withtrade unions’safetyrepresentatives on all proposed actionsrelating to the prevention of workplace stress, managers and supervisorsaretrained on goodmanagement practice, providing confidential counsellingfor staffs if need be and lastly, provisionof resources to implement agreed stress managementstrategies. For example, The Barking, Havering and Redbridge University Hospitals have a stress management policy in place which aim todesign andimplement services, policies and measures that meet the diverse need of their services, people and workforce ensuringthatno one is disadvantaged (BHRUT, 2009). They also aim to improving working lives (IWL), providing staffs with occupationalhealth services andprovidingconfidentialcounselling services (MSWRS, 2007).

Occupational Healthhelps in the setting ofperformancestandards bytheidentification ofhazards, assessment of risk basedon probability andseverity(major, serious and slight), risk control andthe need to monitor andmaintain it ( Cox et al., 2000). In Controlling workplace hazards, potentialhazards are eliminated, employees are restricted to hazards and aretrainedon how todo away with hazards (Smith et al., 1978). Employeesgetadequate information about thename of the hazard, its health effects and the types of exposure (OSHIA, 1970). Safety andhealth is effective in reducing employee risk at work (Cohen & Collagen, 1998).

Employers canuse global objectives (where a percentage of hazard reduction is set) to measure the incidence of workplaceinjury ( Quick & Tetrick, 2002). By this, they could see the viability of a health and safety training programs. Studies show that increasing hourly ratesof employerscan bebeneficial to safety behaviours and reduction in hazardexposure (Hopkins, Conrad & Smith 1986; Smith, Anger, Hopkins & Conrad 1983).

OHP giveemployers the opportunity to know the causes ofstress at work soasto put measures in placetostifle employees fromcapitalising onemployers’negligenceonhealth and safety at work since, as long asemployees havejustified evidence that the employerhas been negligent or breached theirstatutory duty, they will be due forcompensation which affects employersfinanciallybut will enrichemployees. Three examples ofsome compensation cases arethatofpoliceman Martin Long whoearned?330,000 from the Hillsborough disaster in 1989 andthat ofsocial worker ThelmaConwaywho alsoreceived ?140,000 in compensation after she developed stressrelated illness throughwork. Recently, Joyce Walters, a teacher who had a painful nodule on her vocal cord after handling a noisy classroom was paid ?150,000 (Haywood, 2010).


There is more toensuringsafety performance than a written health and safety policy (Smith et al., 1978). Itmust be emphasised thatholding safety programs for organisations are good however, there is the need to encourage communication throughout the various departments inorganisations. Informal communication provides motivation and meaningful information forhazard control ( Quick & Tetrick, 2002).

Curbinginjuries and illness atwork really requires a multifaceted approach that can definehazard, evaluate risk, establish means to control risk and incorporate managementsupervision and employees activelyin theprocess. Topmanagement should have a responsibility to be committed to health and safety programs (Cohen, 1977).The HSE stress indicator tool (HSE, 2007) must alsobe used concurrently to measure stress atwork in order to have a healthy and safer place to work.

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Cohen, A. & Colligan, M. J.(1998) Assessing occupational safety and health training: A literature review. Cincinnati, OH: NIOSH.
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Cousins, R., MacKay, C., Clarke, S.D., Kelly. C, Kelly, P.J, McCaig R.H.(2004)Management standards and work-related stress in the UK: practical development. Work Stress;18. Pp. 113–136
Cox, T, Griffiths, A. & Rial- Gonzalez, E.( 2000). Research on Work Related Stress. Luxemburg.
Engels, F.(1987) Conditions of Working ClassinEngland. London: Penguin Books.
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Haywood, L.(2010) SPEECHLESS: Outrage as teacher gets ?150,000 for losing her voice in ‘noisy’ classroom. The Sun, 10 November, p. 4.
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Free Essays

Promoting Sexual Health


Over the last 25 years sexual health has become one of the most important areas of health care across the world a global pandemic of HIV, the rapid worldwide spread of other sexually transmitted infections and an increasing awareness of sexual health issues by the public globally have all increased enormously the needs of those dealing with sexual health problems to have access to information on theory and practice that can help them adverse the diversity of issues they now face Miller and Green (2002). According to WHO Sexual health is a state of complete physical, emotional, mental and social well-being related to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled WHO (2002). This essay focuses to describe about sexual health, importance of sexual health promotion in teenagers, different levels of interventions, sexual health policies, theories and different sexual health strategies.


According to formally family planning association sexual health defined as the capacity and freedom to enjoy and express sexuality without fear of exploitation, repression physical and emotional harm FPA (2007). Rising STI rates and increasing termination rates DH (2008) indicate there is now a real need to address both issues through progressive work in sexual health care. Indeed, the HPA (2008) highlighted a clear need for people to be aware of how they can protect themselves from unplanned pregnancy and STIs, and the importance of sexual health promotion.

The essay will begin with a brief overview of sexual health promotion in young men and women in UK. The UK has the worst sexual health record in Western Europe while the teenage pregnancy rates and sexually transmitted infections including HIV and sexual violence are increasing. So the importance of sexual health promotion is increasing within young men and women. The aim of this essay is to highlights the need to reduce sexually transmitted infections among teenagers both girls and boys DH (2010) .young people reflects concerns about unintended teenage pregnancies and sexually transmitted infections .Researches are showing that how being young influences sexual behaviours exploring issues including teenage negotiation of contraception and the influence of gender and peer norms both UK and internationally ( Widdice et al. 2006).High rates of sexually transmitted continue to be reported in UK,especially among young people, men who have sex with men and some ethnic minority populations these groups remain at greatest risk infection Miles (2006). I choose the group teenagers (young men and young women) with the age group of 14 to 24for this essay. I selected the teenagers for this assignment because now the rate of teenage pregnancies, sexually transmitted infections, HIV and sexual violence is increasing in UK.


The Importance of sexual health promotion in teenagers is to reduce teenage pregnancies and sexually transmitted infections. Health care providers play a valuable role in educating their patients, and accuracy and completeness of information are the accepted standards in medicine Santelli (2008) Clinicians are held to professional standards involving medical and public health ethics, and are guided by professional health organizations. Guidelines in preventive medicine for HIV, other STIs and unintended pregnancy support the delivery of needed services, including counselling on condom and contraceptive use. Although recognition of evidence-based medicine has been increasing, wide variation exists in medical practices; often, the provider’s judgment is a component in determining patient care. Make awareness about the supportive clinics and provide counselling to the teenagers parents as well AMA (2009).

Sexuality is an important part of one’s health and, quality of life and general well being. Sexuality is an integral part of the total person, affecting the way each individual from birth to death to every single person. A healthy sense of sexuality can provide numerous benefits including a link with the future through procreation, a means of pleasure and physical release, a sense of connection with others and a contribution of self identity Norbun and Rosenfeld (2004). A teenager may go through many physical, mental, emotional, and social changes. The biggest change is puberty that means becoming sexually mature. It usually happens between ages 10 and 14 for girls and ages 12 and 16 for boys. As their body changes, the teenagers may have questions about sex and sexual health. During this time, they start to develop their own unique personality and opinions. Some changes that they might notice including, increased independence from their parents, more concerns about body image and clothes, more influence from peers, Greater ability to sense right and wrong. All of these changes can sometimes seem overwhelming Medline plus (2011).


In the past there has been a confused legal response to creating a balance between protecting vulnerable members of society, and giving people the right to access support for sexual health problems. The legal structure in the UK divides into civil law and criminal law. Legislation can place boundaries on the extent to which health care workers may become involved in promoting the sexual health of an individual. The introduction of the Human Rights Act (2000) has an impact on the rights of the individual and the provision of health care. Criminal law governs people’s sexual behaviour by making some activities unlawful. The purpose of the legislation is to prohibit certain sexual activities and prevent exploitation .To provide young people with the knowledge, skills and confidence to resist any pressure to have inappropriate, early or unwanted sexual relationships and to manage their sexual health .To use discussion about sex and relationships to help young people develop their self-esteem and self-awareness. .To allow young people space to explore their values and attitudes .To encourage young people to make informed decisions about their behaviour, personal relationships and sexual health .To use discussion about sex and relationships to help young people develop their self-esteem and self-awareness Mellor and Williams (2005).


This implies that whether an individual puts protection that is contraception and condoms) into practice depends on the susceptibility to pregnancy or STI infection, severity of that occurrence, the result of implementation of self protection, and the barriers to implementation (Abraham and Sheeran 2005) The motivation theory is a more complex model that contains lots of components such as perceptions of severity, response costs, vulnerability, pleasure and social approval. It also includes belief that the suggested behaviour will reduce the threat and self-efficacy. Self-efficacy is a person’s belief that they can be successful in carrying out the suggested behaviour (Norman et al. 2005)

The theory of planned behaviour is a complex theory. An individual’s perceived behavioural control is the expectation that behaviour is within their control, and therefore is linked to efficacy and autonomy. Within perceived behavioural control lie several factors, including information and skill (Conner and Norman 2005).

Social cognition theory focuses on individual motivation and action based on three types of expectancy. These are the situation outcome, action outcome and perceived self-efficacy. The theories are complex and therefore need further study before putting them into practice NICE (2007) recommended that trained in sexual health care professionals put the theories into practice in one-to-one structured discussions with clients.


Increase the contribution of youth mothers in education, guidance or work to decrease the danger of long term social elimination. The national strategy for sexual health and HIV accepted that the consequences of poor sexual health can be severe leading to amongst other outcomes unwanted pregnancy and termination. The strategy has established a number of key indicators including to increase access to sexual health services, including contraception, particularly to young people. To increase the percentage of young people aged 15-24 accepting screening for Chlamydia. To provide access to Genito-Urinary Medicine clinics within 48 hours DH (2001) .The legal age for young people to consent to have sex is still 16, whether they are straight, gay or bisexual. The aim of sexual offences act 2003 is to protect the rights and interests of young people, and make it easier to prosecute people who pressure or force others into having sex they don’t want. Although the age of consent remains at 16, the law is not intended to prosecute mutually agreed teenage sexual activity between two young people of a similar age, unless it involves abuse or exploitation. Young people, including those under 13 will continue to have the right to confidential advice on contraception, condoms, pregnancy and abortion Mellor and Williams (2005).

To remove the main barriers of sexual health care is to provide health education and that teaches about the sexual health care and care giving clinics. studies show that training in the area of human sexuality and taking sexual histories increases comfort and with addressing sexual health Nussbaum and Rosenfeld (2004).Sex education is offered in many schools, but don’t count on classroom instruction alone. Sex education needs to happen at home, too. Sex education basics may be covered in health class, but the teenagers might not hear or understand everything he or she needs to know to make tough choices about sex. Awkward as it may be, sex education is a parent’s responsibility. By reinforcing and supplementing what the teen learns in school, teachers can set the stage for a lifetime of healthy sexuality. Various factors peer pressure, curiosity and loneliness, to name a few steer some teenagers into early sexual activity. But there’s no rush. Sex is an adult behaviour. In the meantime, there are many other ways to express affection intimate talks, long walks, holding hands, listening to music, dancing, kissing, touching and hugging. If you’re teen becomes sexually active — whether you think he or she is ready or not it may be more important than ever to keep the conversation going. State your feelings openly and honestly. Remind the teenagers that you expect him or her to take sex and the associated responsibilities seriously.

Stress the importance of safe sex, and make sure your teen understands how to get and use contraception. You might talk about keeping a sexual relationship exclusive, not only as a matter of trust and respect but also to reduce the risk of sexually transmitted infections. Also set and enforce reasonable boundaries, such as curfews and rules about visits from friends of the opposite sex.Teenager’s doctor can help, too. A routine check-up can give teen the opportunity to address sexual activity and other behaviours in a supportive, confidential atmosphere — as well as learn about contraception and safe sex. For girls, the doctor may also stress the importance of routine human papilloma virus (HPV) vaccination to help prevent genital warts and cervical cancer MFMER (2009).

Now we are failing young people in their sexual health needs, given an increasing trend in sexually transmitted infections and unplanned teenage pregnancies .significant changes can achieve by numerous endeavours including, equipping young people with the right knowledge, reaching their aspects of themselves which hold significant value in their present day lives to get focus and attention, providing solid basement of self esteem and self preservations in the first place. This must be delivered by open minded, unbiased and non judgemental professionals in a relaxed and friendly atmosphere.HPA (2008). A number of government education initiatives over the last 10 years including the healthy schools status programme. The aim of this curriculum is to support the young people as individual and to improve their concept about sexual health in society. But in some schools trained staff refused to implement this strategies and this act as a barrier of communication with young people DH (2005) sexual relationship education in school by trained confident and up to date professionals, employing straight forward language can make an awareness of pupils existing knowledge Ingham et al (2009).young people’s sexual health clinics are available and confidentiality of service is very important. Condom distribution services are also available locally for young people. Now the sexual health campaigns for teenagers are changed from use of condoms and condom essential campaigns to a new campaign. It aims to improve the knowledge and encourage open communication about relationships among young people, their parents and professionals DH and DCSF (2009).

.the UK is still predominantly a patriarchal society. Gender imbalance can create a negative imbalance in our society. It has a reverse role when it comes to a sexual health provision. Young people’s contraceptive clinics habitually target young females. This stems from a political system desiring to protect itself from the negative consequences of un planned pregnancies ,neglecting young male services to the determent of their sexual health and well being Evans(2008).teenage pregnancy is increasing in UK among highest in Europe by year by year. There are two goals, to decrease teenage conceptions among under18 and get more teenagers parents for education, training and employment to reduce the risk. These goals were accomplished through government media voluntary and private sectors to change young peoples to sexual behaviour DCSF (2010).Health promotion programmes should be adaptable and innovative and offering different methods for feelings and expressions,and opportunities to help build self esteem. There are various economic and social influences contribute hopelessness in young people .young people are trying to express their individuality and find their position in the world Cater and Coleman (2006).According to Department of Health(2009)risk assessment is carried out by three tyre approach they are primary ,secondary and tertiary approach. In primary ,risk to teenagers that means unwanted pregnancy, sexually transmitted infections including HIV ,secondary risk is undiagnosed and un

Symptomatic sexually transmitted infections, infertility and pelvic inflammatory infections etc Territory risk is known as collateral risk to another chronic illness like exacerbation to DM depression or leukaemia .these three approaches allows for effective evaluation of both sexual and holistic consequences of risk taking behaviour among young men and women.

Another example of health promotion planning support is the effective sexual health promotion tool kit. It provides supportive toolkit for the professionals working with young people on sexual health promotion including practical tips for building self esteem and effective health promotion delivery DH (2002). Dating violence is a serious problem among adolescents and young adults. Understanding teens’ reaction to dating violence offer the potential to understand the factors that lead to perpetration of violent behaviour and to elucidate prevention strategies Dating violence, that is, violence between non-cohabitating, but courting individuals includes physical abuse, psychological abuse, and sexual abuse and has been recognized as an international and national public health problem of major proportion A great deal of current research indicates that dating violence is a serious problem among adolescents and young adults today Reyburn(2007).

Using contraception also reduces the chance of pregnancy, but the type of contraception matters, and some methods are typically more effective than others. This essential fact is the key element of the analyses reported by the research team. The investigators guess how an enormous deal of the decrease in teen pregnancy rates might be credited to better contraception by probing shifts in the types of method used at last sex combined with the typical failure rates of these methods. How shifts in contraceptive use might give to declines in pregnancy rates have not been used beforehand improves on previous attempts to estimate the behaviours fundamental changing pregnancy rates. While more teenagers are doing the right thing adults continue to debate whether the reduction in accidental pregnancies is the result of efforts to encourage abstinence or to promote improved contraceptive protection. The analyses offered here cannot distinguish the factors and motives behind reductions in sexual risk taking among teenagers SAM (2004).

The counselling with young people for their sexual health problems, and the importance of sexual health promotion will also help tanagers to get a positive approach to the area of sexual health (Lopez et al. 2008) .Thoughtful, comprehensive approaches from providers are important, given that much of the information adolescents receive on sexuality and sexual risk is erroneous and unhealthy for them (Teitelman et al. 2009). Although this study has explored the content of preventive care received by adolescents at high risk, access to care is also critical, because most adolescents—particularly low-income adolescents, who are at highest risk of pregnancy and STIs do not make normal preventive care visits. For the at-risk adolescents who do present for a clinic visit, it is all the more important to provide effective prevention counselling (Chandra et al. 2008).Pre teenage education and counselling about the prevention of un wanted teenage pregnancies, STIs and HIV to teenagers is very important.

Dual protection refers to strategies that provide guard from unnecessary pregnancy and STIs, as well as HIV. Dual shield can take various forms, including the use of condoms only or the use of condoms with a different form of contraception and the support of emergency contraception, for added safety in opposition to unwanted pregnancy. Except a couple know they are free of HIV and other STIs and are not at risk through sexual activity with others, condoms are the key constituent of double protection. Thus, better interventions are essential which hold up women as

well as men to make use of condoms through sexual intercourse, both for those living with HIV and those who may be in a discordant couple or when one or both partners are engaged in sexual activity with others who may be at risk. Most methods of contraception can be used irrespective of HIV status (Gruskin et al. 2007).

Children and Young People in Wirral are the most significant asset. We should help them all raise into positive and victorious adults. They can do this for themselves but we will help them by ensuring they receive information and services when they are needed and in a way they can best make use of them. We are committed to removing barriers that prevent us from providing the services that children and young people tell us they need Wirral Health and Well Being Charter for Wirral Children and Young People (2008) The aim of the policy is to enable any member of staff to assess and respond appropriately to young people’s needs with regards to sexual health, within their professional boundaries, and from an informed perspective.


To conclude, sexual health promotion in teenagers is a very central matter. Social cultural and political factors can hold back effective communication between health professionals and young people and can put off young people from seeking professionals help regarding sexual health issues. Sexual health promotion will reach the young people at a level that has considerable meaning to achieve change in their sexual practice and to help them to reach their most favourable sexual health and sexual identity. Sexual health promotion in teenagers will assist to reduce the rate of sexually transmitted infections, HIVs, teenage pregnancies and sexual violence.

Abraham, C., Sheeran, P. (2005) the health belief model. Predicting Health Behaviour, Research and Practice with Social Cognition Models. Maidenhead: Open University Press.
2.American Medical Association (2007) Sexuality Education, Abstinence, and Distribution of Condoms in Schools 2007. http://www. [accessed: 22 Sep 2009].
Chandra, A. (2008) Does watching sex on television predict teen pregnancyFindings from a national longitudinal survey of youth. Paediatrics, 122(5), p.1047–1054.
Coleman, L., Carter, S. (2006) planned teenage pregnancy: views and experiences of young people from poor disadvantaged backgrounds.
Conner, M., Norman, P. (2005) Predicting health behaviour: a social cognition approach. Predicting Health Behaviour. Maidenhead: Open University Press.
DCSF (2010) teenage pregnancy strategy [online] available at:
Department of Health (2001) the National Strategy for Sexual Health and HIV Department of Health. London
Department of health (2002) effective sexual health promotion: a tool Kit: for primary care trusts and other working in the field of promotion of good sexual health and HIV prevention. [Online] available at:
Department of Health (2003) Effective Sexual Health Promotion Toolkit: a Toolkit for Primary Care Trusts and Others Working in the Field of Promoting Good Sexual Health and HIV Prevention. Department of Health: London.

10. Department of health (2005) national healthy school status: a guide for schools. DH: London.

11. Department of health (2009) moving forward: progress and priorities working together for high quality of sexual health. Stationary office: London.

12. Department of Health (2008) Abortion Statistics, England and Wales: 2007. London: DH.

13. DH (2010) publications, policy and guideline: primary secondary and tertiary prevention on. The stationary office London.

14. DH and DCSF (2009) sex worth talking about, www.dcsf, [accessed in March 2010].

15. Evans, D. T. (2010), sexual health: exploring risk, promoting sexual health course, unpublished course material, Greenwich university.

16. Evans, D.T. (2008) unit 2 sexualities and sexual health, sexual health skills course, university of green which.

17. Family planning association (2007) sexual health a public health issue. British journal of school nursing, 2 (3), p .102-106.

18. Gruskin, S.,Ferguson, L.,Malley .J ,O.(2007) ensuring sexual and reproductive health for people living with HIV :an overview of key human rights ,policy and health system issues ,reproductive health matters , 15 (29), p. 4- 26.

19. Health protection agency (2008) spot light infections. [Online] available at:www.hpa .org .UK.

20. Health Protection Agency (2008) All New STI Episodes Seen at GUM Clinics in the UK: 1998 – 2007. London: HPA

21. Ingham, R., Nauserzadeh, S., Stone, N. (2009) SRE conference hand book 4th biennial international sex and relationships conference.

22. Lopez LM et al., Strategies for communicating contraceptive effectiveness, Cochrane Database of Systematic Reviews, 2008, Issue 2, No. CD006964.

23. Mayo foundation for medical education and research (2009),

24. Medline plus (2011), US national library service of medicine.

25. Mellor, R. and Williams, D. (2005) sexual health of looked after children and care leavers .amended health and well being team.

26. Miller, D. and Green, J. (2002) the psychology of sexual health.6th ed. Black well science publication: lowa state university press.

27. NICE (2007) One to one Interventions to Reduce the Transmission of Sexually Transmitted Infections (STIs) Including HIV, and to reduce the Rate of Under 18 Conceptions, Especially Among Vulnerable and At RiskGroups.London: NICE.

28. Norman, P. et al (2005) Protection motivation theory. Predicting Health Behaviour. Maidenhead: Open University Press

29. Nusbaum, M. and Rosenfeld, J .A. (2004) sexual health across life style ..cambridge university press.

30. Rayburn, N. R.,Jaycox, Z. H .,Mccaffery ,D. E. ,Ulloa, C., Marshall, G. N., Shelly ,G. A., (2007)reactions to dating violence among Latino teenagers :an experiment utilizing the articulated thoughts in simulated situations paradigm, journal of adolescence ,vol,30, p .893-915.

31. Royal collage of nursing (2000), sexuality and sexual health in nursing practice in London, quoting publication, code 009965.

32. Santelli, J.S. (2008) Medical accuracy in sexuality education: ideology and the scientific c process. American Journal of Public Health, 98(10):1786–1792.

33. Society for adolescent medicine (2004) confidential health care for adolescents: position paper of the society for adolescent medicine. (35), p. 80-90.

34. Teitelman, A.M., Bohinski, J.M. and Boente, A. (2009) the social context of sexual health and sexual risk for urban adolescent girls in the United States. Issues in Mental Health Nursing, 30(7), p.460–469.

35. WHO (2007) sexual health, gender and reproductive rights.

36. Widdice, L. E., Cornell, J. L., Wendra, L. & Halpern-Felsher, B. L. (2006) ‘Having sex and condom use: potential risks and benefits reported by young sexually inexperienced adolescents. Journal of Adolescent Health, vol. 39 (4), p. 588-595.

37. Wirral Health and Well Being Charter for Wirral Children and Young People (2008).

Free Essays

Principles and practice of mental health nursing


This essay will discuss the development of Cognitive Behavioural Therapy (CBT) and its role in mental health nursing. A brief definition of CBT will be given, and treatment modalities used before the advent of CBT for the treatment of anxiety will be explored. The essay will evaluate the principles and practice of CBT, and equate this with the recovery process. The essay will also explore two CBT approaches that can be use to work with anxiety. The limitations of CBT will be discussed, likewise the relevance CBT to mental health nursing. The essay will be concluded by highlighting the learning I derived by writing this essay.

CBT is an umbrella classification of the different approaches in psychotherapy treatment which helps patients to understand how their thoughts and feelings influence their behaviour. CBT is evidenced based, collaborative, structured, time limited, and empirical in approach (Westbrook et al, 2007). According the National Institute for Health and Clinical Excellence CG22 guideline, (2010) it should be recommended to patient and carers for the management of major mental health problems. The CBT process normalise recovery which is important in therapeutic alliance as oppose to the medical model of care which pathologies recovery. The socialization process fit with that of the recovery model both of which are patient centred, giving hope and optimism to the patient, and using a set of outcomes set by the patients (Till, U. 2007).

According to Hersen, M (2008), the earliest origin of CBT can be traced back to the times of Siddhartha Gautama (563-483 BC) and Epictetus (A.D. 50-138) both of whose work reflected the concept of CBT in their teaching. CBT was developed from two parts way: ‘Behaviourism’ and ‘Psychoanalysis’

Behavioural therapy was developed from the principles of animal learning to humans from two main principles called classical and operant conditioning (Shawe-Taylor & Rigby, 1999). Classical conditioning theory was based on the work of Pavlov (1927) while “Operant Conditioning” theory was based on the work of Skinner (1938). Psychoanalysis was developed by Sigmund Freud and looks at the functioning and behaviour of human. BT arose as a response to the psychodynamic image, when Freudian psychoanalysis was questioned for its lack of a scientific base.

The application of behavioural science resulted in merging CT & BT approaches, resulting to the treatment of anxiety disorder and inappropriate behaviours, and little progress in depression and psychosis (Shawe-Taylor and Rigby, 1999). However, the failure and criticism following the use of strict behavioural concept to explain complex behaviour brought about the emergence of the cognitive behavioural therapy. The major difference between the two approaches is the inclusion of the meditational approach in CT. (Hersen, M and Gross, A. 2008). Rational emotive behavioural therapy (REBT), developed by Albert Ellis (1913-2007) was one of the treatment approach used during this period.

CT was developed in the 1960’s by Aaron Beck, and this approach became popular for its effective treatment of depression. The significant result from the merge of BT & CT was the outcome of treatment for panic disorder by both Clark and Barlow in the UK and US respectively. Their combination in the 80’s and 90’s has resulted in CBT being a sort after therapy for mental health disorders.

Anxiety is an example of a mental health problem. Anxiety is a common and treatable mental health disorders which manifest as feelings of uneasiness such as worry or fear which could be mild or severe, and a normal part of human condition Barker (2009). The feelings of fear and worry are sometimes helpful in psychologically preparing us to face the problem and physically triggering the flight and flight response. This affects 1 in every 10 people (RCPSYCH, 2010).

The major types of anxiety disorder are: generalised anxiety disorder, panic disorder, obsessive compulsive disorder (OCD), post traumatic stress disorder and social phobia or social anxiety disorder. The symptoms of anxiety manifest through the mind via frequent worries, lacking concentration, feeling irritable, feeling tired and sleeping badly. While in the body symptoms include palpitations, sweating, muscle tension, fast breathing and faintness (RCPSYCH, 2010). Social anxiety disorder is use for discussion in this essay.

Treatment modalities before the coming of CBT include those from psychoanalysis and Behaviourism. Anxiety treatments available before CBT include: refraining people from excess exercise in other not to increase the strain on the nervous system, administering Strychnine, arsenic and quinine and applying a white hot iron along the spine in severe cases. Exposure treatment which is still being use till date, use of Radionics by attaching patients to various devices with the belief that healthy energy is vibrated to unhealthy parts of the body, Use of Rational emotive behaviour therapy (REBT), and the use of Gamma-amino-butyric acid (GABA) facilitating drugs. Insulin shock therapy was also used (Marlowe, J 2011)

Cognitive approaches use in working with social anxiety is: cognitive restructuring and exposure therapy. Cognitive restructuring according to Heimberg and Becker (2002) is the identification and challenging of irrational thoughts, which include beliefs, assumptions and expectations and replacing them with those that are rational, realistic and adaptive. The principle is not only challenging the negative thinking pattern that contribute to the anxiety, it also helps to replace them with more positive and realistic thought pattern by suggesting alternatives and by reinforcing the client belief in the alternative interpretations and ideas suggested (Norman and Ryrie, 2009).

For a person having a fear of public speaking in social anxiety disorder, the way he or she feels is not determined by the situation but by his or her perception of the situation, thus the thought, emotion and behaviour is important in therapy. The therapist, in collaboration with the client uses the situation-emotion-thought-behaviour (SETB) to structure how the treatment will go. Cognitive restructuring is done in three steps, with full collaboration between the client and the therapist after building up a working therapeutic relationship. The first step is identifying the content and occurrence of the unhelpful thought. The therapist will ask the client to write down his or her thoughts, using thought monitoring records. Client may come up with thought like: I am not good at preparing speeches; I will make a fool of myself, or what will people think if I say the wrong thing. The therapist starting question could be, “If we could make one thought go away, which one will you choose to make a difference in the way you feel”, or “what is the worst thing that could happen?” Such questions are asked to uncover underlying fear. (Norman and Ryrie, 2009, Padesky and Greenberger, 1995).The second step is challenging the negative thoughts. Here, the therapist will help to dispel the irrational thoughts and beliefs to loose much of its power over the patient at this stage. The third step is replacing the negative thoughts with realistic thoughts which are more accurate and positive, with the therapist teaching the client about realistic calming statements he/ she can say when such anxious situation comes up.

Systematic desensitization is a type of behavioural therapy use to treat social anxiety. It was developed by Joseph Wolpe, a South African psychiatrist. Systematic desensitization also called graded exposure, is the process of facing the anxiety or fear producing triggers from the less feared to the most dreaded ones, and the pre – planned grading of the triggers for exposure is referred to as “hierarchy” while habituation is “the reduction of anxiety over time when a person encounters an anxiety or fear – provoking trigger without the use of safety behaviours” (Norman and Ryrie, 2009). Systematic desensitization helps a client to gradually challenge his or her fears or anxiety, build confidence over time and master skills for controlling his or her anxiety. The process involves the therapist first teaching the client some relaxation techniques like deep muscle relaxation and assesses their ability to utilise this. For example, a person who is anxious of facing the public and due to give a lecture, the step is to create a hierarchy of the anxiety or fear experience. The questions the therapist can ask to evoke triggers are: “What places, thing or people make you uncomfortable“What brings your fear/anxiety/worry on(Norman and Ryrie, 2009). Then the therapist ask the client to set an exposure task according to his hierarchy of triggers, which should be graded, focused, repeated, and prolonged using the daily exposure diary. The client then work through the list with the guardian of the therapist, and the goal is to stay in each situation until the anxiety or fear subsides. The whole process is carried out with both parties collaborating together to achieve the goal, first through “in vivo exposure, such as imagining giving a speech and when the situation become easier, then the client progresses to the situation in the real world. The use of home work is also use.

Despite all the good attributes associated with CBT, it is not without its own limitations. CBT is very complex to implement having a poor outcome with substance users who have a higher level of cognitive impairment (Patient UK). The availability of well trained and experienced qualified therapist is hard to get in the rural communities (Robertson, 2010). CBT does not work for everybody, and requires high commitment from the patient who see the home work as difficult and challenging (Patient UK). Some aspects of CBT therapy cannot be applied on people with learning disability and language is a barrier for those who English is not their first language.

Nurses interact and undertake more roles with patient, and they are the first contact complaints are made to, which could give them an opportunity to offer CBT skills in the nursing process if it was incorporated in their training. (Padesky and Greenberger, 1995) Thus, the teaching of basic CBT skills is now being incorporated into the curriculum of the Mental Health Nursing pre/post registration programme. According to Gournay, K (2005), mental health nurses are now taking up challenging roles in management and nurse prescribing, giving advantage of freeing up the psychiatrist to undertake the more complex cases. The case for a nurse cognitive-behavioural therapist has been made glaring by the shortage of qualified therapist as a result of the widening evidence base for the approach and the recommendation by the NICE guidance for the provision of CBT for the treatment of hallucination and delusions (National Institute for Clinical Excellence, 2002). As recovery is all about inspiring hope to the patients, the mental health nurses will be better equipped to offer a person centred care required for patient recovery. The incorporation of CBT to mental health nurses curriculum will prepare nurses to be more collaborative in approach, and allow patients to have more input in their care which will improve the therapeutic relationship between the nurse and the patient and make nurses more approachable. With the advent of computer based CBT, the need for patients to meet with the therapist on a one on one basis is reduced, thus addressing the shortages of therapist and opening a new window for the people who are depressed or withdrawn to use the approach. (Robertson, 2010). There is prospect for mental health nursing considering the boost in career prospect this will bring to the profession and their position in the multidisciplinary team.

This assignment has been an eye opener for me as a mental health student. It has exposed me to various issues in mental health, past & present. And given me the opportunity to plan ahead of the future in shaping my direction in the profession. The essay has also given me the opportunity to know about the history of CBT and the various treatment approaches used before its era. It has given me the opportunity to see the interrelationship between CBT and recovery in care practice and also shown me that CBT skills will greatly enhance the quality of care provided by the mental health nurse. CBT should be made mandatory for all mental health nurses as a matter of necessity.


Barker, P. (Ed) (2009) Psychiatric and Mental Health Nursing: The craft of caring 2nd edn. London: Hodder Arnold.

Gournay, k. (2005) ‘The changing face of psychiatric nursing: revisiting mental health nursing’, Advances in psychiatry treatment, 11, pp. 6-11 RCPSYCH (Online). Available at:

Hersen, M. and Gross, A. (2008) Handbook of Clinical Psychology. Volume 1. John Wiley & Sons.

Heimberg, R. and Becker, R. (2002) Cognitive-behavioural group therapy for social phobia: basic mechanisms and clinical strategies. 1st edt. New York: Guilford Press.

Marlowe, J. (2011) ‘Historical treatments for anxiety’ (Online). Available at:

Norman, I. and Ryrie, I. (2009) The Art and Science of Mental Health Nursing. 2nd edn. Milton Keynes: Open University Press.

National Institute for health and clinical excellence (2010) Summary of cognitive behavioural therapy interventions recommended by NICE. Available at:

Padesky,C. and Greenberger, D. (1995) Clinicians Guide to Mind Over Mood. London. Guilford Press.

Patient UK (2011) what is cognitive-behavioural therapyAvailable at:

RCPSYCH (2010) ‘Anxiety, Panic and Phobias’. Available at: (Assessed: 4 March 2011).

Robertson, D. (2010) The Philosophy of cognitive Behavioural Therapy: Stoicism as rational and cognitive psychotherapy. London: Karmac.

Shawe-Taylor, M. and Rigby, J. (1999) ‘Cognitive behaviour therapy: its evolution and basic principles’, The Journal of The Royal Society for the Promotion of Health, 199(4), pp. 244-246.

Till, R. (2007) ‘The values of recovery within mental health nursing’, Mental health practice, 11(3), pp.32-36.

Westbrook, D. Kennerley, H. And Kirk, J. (2007) An Introduction to Cognitive Behaviour Therapy- skills and applications. London: Sage.

Free Essays

‘Sex and sexuality: a cultural taboo’. Critically discuss and analyse the role of culture in sex and sexuality and impact on health.


There is high recognition for morality, family life, community life, sociability and solidarity. This is shown through initiation, stories and rites of passages, but could differ from tribe to tribe and from culture to culture. The issue of sex and sexuality is often challenging where tradition is deep into their ethos. The role of cultural taboos through the ages has an impact on one’s identity, self-esteem, relationships, health and societal traditions is more real than is often imagined. This essay will critique how cultural taboos play a role among the girl child and women as a group in the Ghanaian culture and its impacts on their sexuality and health.

Critically examine culture, look at how cultural practices impact on general health and lives of its members.

Sexuality impacts widely on our lives because it differentiates and set us apart. This starts of how we feel inside as men and women. Sexuality is central throughout life and includes sex, gender, identities and roles, pleasure, intimacy and reproduction in the view of Nye, (1999), with culture expressed in desires, thoughts, beliefs, attitudes, values and behaviours. However while all these aspects can include of sexuality, not all of them are practiced. They can also be influenced by social, cultural, legal and religion (Parker & Aggleton, 1999 and WHO, 2004). These are practices that reflect their values and customs which holds the members of the group for many generations. Cultural practices consist and reflect their values held by members of the members of a given group hold, the norms they follow, and the material or goods they create. In the world today, there are many social groups or cultural groups with specific traditional cultural practices and beliefs of which are beneficial to its members, while on the other hand presents harmful and negative impact to a specific group, such as women, who such cases are the receiving end. Such harmful cultural practices include female genital mutilation (FGM); forced feeding of women, early marriage, taboos and practices which prevent women from controlling their own fertility, nutritional taboos and birth practices, dowry price and son preference and its implications for the status of the girl child (Hosken, 1994).

Identify one particular cultural group and critically examine sex and sexuality how it is accepted and portrayed

The issue and discussion of sex and sexuality is viewed as a taboo and shameful by many cultures and it is simply not discussed. Taboos in this sense are put in place to ensure that norms and traditions are adhere to such as no sex before marriage and men sleeping with men (White, 1984).

There is also some veil of secrecy surrounding sex. To openly discuss sex with older adults is considered a sign of promiscuity. Issues of sex and sexuality have great implications on women as a group to exercise their feminism. Whether for procreation or carnal gratification, sex in the traditional African context is a thing not be trifled with. Traditionally in this context, sex is restricted to family life and only persons who are joined in marriage are expected to have sex. In the view of Kosemani (2005) ‘when it comes to the question of what the African scale of value is,’ sex relates to the totality of the human condition. Any deviation from that is faced with stigmatization.

Female genital mutilation (FGM) or female genital cutting (FGC) is widely practiced among the northerners, an ethnic group mainly found in the northern part of Ghana. This practice among these groups appears to be associated with spiritual roots, tradition and tribal beliefs (ref). It forms part of the rites of passage ceremony marking the coming of age of the girl child. To this group, by removing the female’s genitals, her sexuality will be controlled; but the main aim is to preserve a woman’s virginity before marriage and chastity thereafter (Hosken, 1994).

Normally young girls from age 7 to puberty age are circumcised, however for a girl attainting puberty and not being circumcised is regarded as a taboo and an abomination. The belief is to deter these girls from experiencing early sexual activities and unwanted pregnancy, sexual transmitted infections and unsafe abortions. Also, it is believed that by performing this practice it leads to cleanliness and fidelity of the woman, therefore making her sexually attractive for any prospective husband. Women who object to this practice are regarded as unclean, less attractive and less desirable for marriage; that is how their views on sexuality are expressed (Osho, (2005). The acceptance of FGM among this group is deeply rooted in their custom or tradition and has being practiced for many years by generations. The practice of FGM leaves a negative label on women and the girl child such as psychological problems and this violates the right to enjoy the highest attainable standard of health of the convention on the rights of the child (United Nations, 1979).

The early marriage of girls as opposed to boys is also practiced amongst this culture. Normally girls around the ages of 11-13years and reaching the age of puberty must be given away in marriage and start having children otherwise it’s a taboo. Such practices are not only seen among this ethnic group but prevalent in Asia and Africa. Jenson and Thornton (2003) argue this practice exist because of the girl virginity of the girl and the bride-price, and believe these girls are virgin and have had no sexual contact therefore this raises the status of the family.

In many cases her virginity would have to be verified senior female relatives before the marriage. This practice robs the childhood-time essential to the development of these girls physically, emotionally and psychologically. In many cases, the man would be many years older (Singh and Samara, 1996). With this circumstance, she is to develop an intimate emotional and physical relationship and adhere to sexual contact, although she may not be physically ready. A label is placed on a girl or woman as promiscuous if she refuses or fails to abide by the tradition. Sometimes a spell may be cast on her or sent out of the village for flouting the tradition.

What are good about these practices and what is not so good

Referring to the above situations, it is clear that sexual taboos thus put a lot strain on parents and other siblings by allowing them to go through the initiation. The negative implication of sexual taboos is that it does not allow dialogue between parties. The world is now a global village with globalization spreading everywhere; this makes girls more aware of such negative practices. By keeping silence, sexual taboos are allowing indirectly unreasonable and irresponsible sex or promiscuity so that she won’t be give out to an old man in marriage therefore not be able to enjoy her youthful days and having fun. As they defy these taboos, it results in broken hearts, broken homes, sex scandal and HIV/AIDS.
On a positive note, sex taboo forms a code of sexual conduct that in a sense is deeply and highly regarded that any deviation from it is detested. However, parents especially women must stand up and break this silence of sexual taboos and cultural beliefs which fuel the spread of emotional pain, diseases and infections. The sacred manner in which sex is held isemphasizing on the positive use of sex firm and basic that it is necessary for people to understand such importance people place on sex, therefore the positive point is the need to stress on it use (Kosemani, (2000).

Health impact

The health impact of FGM on women does irreparable harm. In many cases women experience severe bleeding which can lead to death and hemorrhagic shock, infection and septicaemia. Physical effects of this practice make the wound not heal properly leading to severe pain during sexual intercourse this increases the susceptibility to HIV/AIDS and other sexually transmitted infections including reproductive tract infection, infertility and increased risk of bleeding and infection during child birth (Carovano 1992). In view of that it makes the situation quite difficult for women to be informed and seek adequate knowledge about the risks, but even when informed about risk, it makes it difficult for them to be involved in the negotiating of sex which often as a result of unawareness, embarrassment and unavailability of proper service of information. As motherhood, like virginity is highly considered to be a feminine ideal, the use of contraceptives as safer sex option thus pose a major dilemma for most women (Heise and Elias 1995; UNAIDS 1999).

Health complications that result from early marriage in include the risk of operative delivery, low weight and malnutrition resulting from frequent pregnancies and lactation in the period of life when the young mothers are themselves still growing. According to Weiss and Rao Gupta (1998) this practice does not allow the girls to indulge in illicit sex, exchanging sex for money and not perusing any risky behaviour. The stigma and embarrassment associated with sex and sexuality can lead to unwillingness to discuss and address sexual health issues.


The role of culture in sustaining such practices cannot be overemphasized. Women often see themselves as weaker vessels and therefore accept these tradition and taboos that give men the power to dominate over women in all matters and spheres of life including the expression of sexual desire. The need for education will helps in the development of virtues of the mind.

Free Essays

Climate Change is the Biggest Global Health Threat of the 21st Century.


Climate change is one of the major environmental threats facing the world today. It is referred to as “any distinct change in measures of climatic condition that could last for a long period of time such as major changes in temperature, rainfall, snow or wind patterns lasting for a decade or longer” (Allen, 2010). Over the past century, there has been a continuous rise in the levels of carbon dioxide (CO2), methane and other green gases (Frumkin et al, 2008) as well as the earth’s surface being warmed by more than 0.8°C and by approximately 0.6°C in the past three decades (NASA, 2007). It has been estimated that by the year 2100, the world’s mean temperature will increase by an additional 1.8 to 4.0°C, sea levels from 0.18 to 0.59m and a significant increase in weather variability (Solomon et al., 2007). The warming of the earth’s surface has brought about severe weather conditions such as torrential rains and flooding, droughts and storms which are as a result of human activities such as the burning of fossil fuels which are rich in carbon and combine with oxygen in the atmosphere to release carbon dioxide that traps heat in the atmosphere (Change, 2007). The annual emissions of CO2 and GHG have increased by 80% and 70% respectively between 1970 and 2004 (Allen, 2010). Deforestation is another human activity that has brought about the continuous change in climatic conditions (Change, 2007).

Global Implications of Climate Change.

It has been estimated that by the year 2015, Global Millennium Development Goals and the assurance of a safe and sustainable future will be harder to obtain due to the changes in the climate (Allen, 2010). Instances of natural disasters that have happened recently are shown below:

The first hurricane ever recorded in the southern Atlantic Ocean in Brazil in 2004 and the Cyclone Nargis which raised a tidal wall 12feet high and forty kilometres long that slammed into Myanmar (Burma) in 2008 are examples of the fact that the earth is changing fast (Epstein et al, 2011 ). In 2003, a heat wave melted 10 percent of the ice in Alps and killed more than fifty two thousand people. One thousand people were killed as a result of a drenching rain in Mumbai which also contaminated water supplies and sickened hundreds. This has led to the spread of “malaria-carrying mosquitoes, the disappearance of mountain glaciers which threatens drinking water supplies on five continents and at least 150,000 additional deaths recorded worldwide each year as well as five million years of healthy life lost to disability” (Epstein et al, 2011).

Health effects of climate change

Climate change affects health in several ways namely: continuous change in disease and mortality patterns, severe weather events, food and water contamination, heat wave, melting permafrost and threats to housing and public infrastructure (Costello et al., 2009, Healey et al, 2011). The major factors affecting human health are “social, political, economic, environmental and technological factors as well as urbanization, affluence, scientific developments, individual behaviour and vulnerability in terms of genetic make up, nutritional status, emotional well being, age gender and economic status” (Allen, 2010).

Other potential health effects of climate change include respiratory and cardiovascular disease related to worsening air pollution, infectious diseases related to changes in vector biology, water and food contamination, nutritional shortages related to changes in food production, allergic symptoms related to increased allergen production (Heinz and Patz, 2004, Heinz et al, 2006). The way pests, parasites and pathogens affect wildlife, livestock, agriculture, forests and coastal marine organisms can also alter ecosystem composition and functions, and changes in these life support systems carry implications for human health” (Epstein, 2005).

The adverse health effects of climate change will also bring about migration from flooded and inhospitable places which will encourage population growth, thereby, resulting in “increased pressure and competition for scarce resources, such as food, water and shelter” (Costello et al., 2009). The demand for more food production will give rise “to high land loss and as a result bring about industrialization, urbanisation, sea level rises and increased flooding” (Costello et al., 2009).

Figure 1 summarises the major pathways through which population health can be affected by climate change. The right hand boxes show an increase in complexity of causal process where the likelihood that health effects may be deferred or protracted while the middle boxes show the main climatic-environmental manifestations of climate change (McMichael et al., 2006).

Climate Change and Health Model

The effect of climate change will be greatest on countries that have made little or no contribution to its cause and those with little resources. The implementation of mitigation and adaptation helps to reduce inequity caused by negative effects on social determinants of health in the poorest countries (Costello et al., 2009).

Mitigation can be described as the true prevention/intervention to lessen adverse health effects (McMichael et al., 2006). One of the most important factors in mitigating the effects of climate change on health is to bring to focus the past, present and the future events which have contributed to the transition of land, environment and the way of life of people (Healey et al, 2011). To avoid dangerous climate change, mitigation is required to “reduce greenhouse gas emissions and increase carbon biosequestration through reforestation and improved agricultural practices as well as to ensure a rapid, sustained and effective coordination of global and regional action” (Costello et al., 2009).


Climate change adaptation is required for an improved coordination and accountability of global governance. Climate change health effects can be managed when all sectors of government, civil society and academic disciplines work together to get to an expected end. It is crucial that the local communities get involved in monitoring, discussing, advocating and assisting with the process of adaptation (Costello et al, 2009). Local action is required for the prevention of local flooding and global action to make funds available as well as the needed cooperation of government and international agencies to reduce health inequalities in communities (Costello et al, 2009). Some examples of adaptation measures to climate change are shown in table 1.

Table 1: Some examples of adaptation measures to climate change. (Sourced from Bulto et al, 2006)

Adaptation optionsCurrent activitiesFuture activities
Strengthening primary health care and the public health systemSpecific health promotion and preventive programs designed to reduce population vulnerability. Educational programs of environmental risks, including climate change and their effects on human health.Continuous development of health promotion and preventive programs, increasing community participation on health issues, increasing the participation of local governments and other sectors in developing the best conditions of life.
Measures to improve health surveillance systemsProviding forecasts of the main climate-sensitive diseases to all levels of the National Public Health System increase number of early warning systems to predict epidemics.Continuous research to improve forecast models using the necessary indices.

Incorporating new diseases and risk factors in the forecast models.

Decreasing uncertainty through improved data and research on climate, epidemic, ecologic and social variables.
Immunization programs, especially for high-risk groupsMaintaining the current vaccination program and prioritizing new programs.Enhancing vaccination programs immunization program and develop a prevention program for diseases.
Improve sanitary conditionsDeveloping responses to increased sanitary demands in all fields (communal, drinking water, garbage, sewage, food, and others). Maintaining contingency plans.Developing educational programs about environmental care with the participation of the community, government, and all sectors. Increasing environment care projects. Improving contingency care projects.
Educational programs on radio and TV and newspapersDevelop educational programs on the health risks associated with climate change Implementing new programs on climate-health associations and communicate results to the population, governments and others.
Exchange information with international researchers working on climate change and health issuesParticipate in international meetings.Develop new projects with participation from other countries.

Other Strategies and Interventions

Public health services are very essential for reducing the challenges brought about by climate change. The services can help to “monitor the health status of the community, investigate and diagnose health problems and hazards, inform and educate people regarding health issues, mobilize partnerships to solve community problems, support policies and plans to achieve health goals, enforce laws and regulations to protect health and safety, connect people to required personal health services, ensure a skilled, competent workforce, evaluate effectiveness, accessibility and quality of health services, research and apply innovative solutions” (Allen, 2010).

The health and well being of humans can be increased by developing a variety of strategies for coping with climate change and reversing its ill effects such as recycling materials. These would greatly help to improve personal choices, enhance sustainability, discourage waste and clean up communities (Healey et al, 2011). Another strategy is to create awareness about the effects of climate change by ensuring individuals are educated and well informed as well as engaging people in political action to strengthen communication and ensure more equitable access to facilities (Healey et al, 2011).

Interventions put in place to reduce the declination of global freshwater resources caused by rising rates of water extraction and contamination are to scale up water and sanitation services which would help to reduce infectious diseases and avoid the health impacts of decreasing water supplies.

Community participation and social mobilization are needed for addressing health concerns and creating healthy environments. The public health community needs a realistic preventive strategy to make sure healthy environments are maintained and developed from local to global needs as well as a sustainable development and protection of ecosystem services which are very important for human health (WHO, 2005).


In conclusion, climate change should be addressed as an integral part of the big challenge towards a sustainable development. This can be achieved by encouraging communities to get more involved in working towards actualizing change at multiple and socio-ecological levels (Healey et al, 2011). Further attention needs to be placed on this issue by the government as well as the maintenance of public health infrastructure by providing adequate funds for environmental and chronic disease surveillance systems and a well trained work force (English et al, 2009).

Free Essays

Vector-borne bacterial and parasitic diseases have developed or re-developed in a lot of geographical regions inducing economic problems and global health which include livestock, companion animals, wild life and humans.


Recently, vector-borne bacterial and parasitic diseases have developed or re-developed in a lot of geographical regions inducing economic problems and global health which include livestock, companion animals, wild life and humans. Globally diseases that their transmission occurs via arthropod vectors are the main significance to the health of animals and humans. Furthermore these diseases and their epidemiology associated with a range of hosts, infectious agents and vectors. As result of an oversupply of factors, is the over time change of disease patterns that also vary from one geographic zone to another.

Infectious agents included in developing pathogens have been showed in other regions and were introduced into already unknown areas. However, agents that were continually showed on a low level or in a different host in the affected area and owning to some modification have appeared more broadly spread in the population. On the other hand those were not previously recognized and the organisms that have been classified and correlated with a new disease with an unknown etiology. Conversely, for disease such as piroplasmosis naive wildlife or domestic animals transmitted into an endemic region has resulted many times in epidemic outbreaks. Unexpected induction of disease vectors like mosquitoes or tick species originating at one area to another eventually could be reliable for the spread of infection to new regions. Over the last two decades, the progress in molecular biology has also led to a new vector-borne pathogenic organism’s discovery. These bacteria transmitted by arthropod and have been correlated with disease syndromes such as peliosis hepatis, bacillary angiomatosis, endocarditis and cat scratch disease. The most prevalent vector-borne disease that became known just over 20 years ago in North America as a new disease with a spirocheatal causative agent is the Lyme disease which has been exposing as a main pathogen of dogs and humans represented by molecular detection of historical specimens.

Clearly, climatic and demographic changes affect the global distribution of vector-borne protozoan pathogens. At first, epidemiology and ecology of vector-borne diseases are affected by three main factors constituting the host, the environment and the pathogen. Main factors that are reliable for the spread and evolution of vector-borne parasites contain modifications in irrigation habits and water storage, climate and atmospheric changes, habitat changes, public health and evolvement of drug resistance and insecticide pollution. Global or governmental or war and civil unrest management failure are also the main factors that are associated with the spread of infectious diseases. In the last two decades, the progress in epidemic understanding and planning even with the evolution of recently diagnostic molecular techniques have permitted researchers to better diagnose and trace pathogens, helped to establish intervention programs, their source and routes of infection and defensive public health. An important responsibility of veterinarians, physicians, biosecurity officers and health care workers is the future vector-borne disease prevention. A corresponding global approximation for the vector-borne disease’s prevention should be achieved by governmental agencies and international organizations in association with research institutions.

Moreover, an important factor which affects the global distribution of vector-borne protozoan pathogens is habitat change which is a result of widespread land use, agricultural development, deforestation and modifications in irrigation habits and water storage which supply new niches for vectors. Transformation and deforestation of forests to human settlements or open areas, grazing land and agricultural areas, which are result of important changes in the environment and in the structure of vectors, and thus, the induction of new pathogens. Other widespread changes, like deforestation and agricultural practices, increase the transmission risk for vector-borne disease. In the past 50 years, several irrigation systems and dams have been developed except regard to their effect on vector-borne diseases. Furthermore, agricultural practices like rice production has increased and also tropical forests are being cleared at an enhancing rate. Ideal breeding sites for domesticated mosquitoes are formed by consumer products. Products that tend to be disposed in the environment where they collect rainwater are those packaged in cellophanes, nonbiodegradable plastics and tin. An excellent mosquito breeding places are the several disposed automobile tires in the domestic environment. The global used tire industry and container shipping have conduced to the raised geographic distribution of selected mosquito species that lay their eggs in used tires. In the Thar Desert in north-western India where occurred the Plasmodium falciparum malaria evolution and Anopheles culicifacies spread and establishment which followed the development of irrigation canals. The world is encountering the development and substantial urbanization of human population. Moreover in Senegal the construction of the dam at Diama was intended to intercept the invasion of seawater into the river and as a result the salinity reduction and increased water pH thus increasing the development and fecundity of freshwater snails and the exposure of humans in the lower and middle valleys of the Senegal River Basin to Schistosoma mansoni. Development of new contacts changes in the new massively inhabited environment caused by the movement of people from rural areas to urban centers. Generally more susceptible to the endemic diseases are the newcomers to which they may not be immune. Furthermore in the new environment have the induction of new vectors and pathogens. Below these circumstances, the opportunities of parasites and vectors are increase for transmission and exchange. In past 50 years the global societal and demographic alterations have directly contributed to the vector-borne and other infectious diseases regeneration. Generally uncontrolled and unplanned urbanization in evolving countries causes the worsening of public health infrastructure, management systems of water, sewage and waste. New roads construction supplies means of vector and host transportation. As result of these changes is the formation of optimal situations for the vector-borne disease’s transmission to large populations. Finally, the jet airplane has had a profound influence on rapid global transportation. Airplane travel provides an easy means for transporting pathogens between population centers. The result is a constant movement of viruses, bacteria, and parasites among cities, countries, regions, and continents.

Also another factor that induces global distribution of vector-borne protozoan pathogens is public health. Decisions of policy for public health have greatly reduced the surveillance resources, that principally because control programs had decreased the menace of public health from vector-borne diseases as a result reduced the prevention and control of those diseases. However, the drug resistance and technical problems of insecticide which are also public health decisions, have an important function for the regeneration of diseases like malaria and dengue. The result of the cessation or merger of many programs usually are the reduced resources for infectious diseases and eventually to the worsening of the public health infrastructure needed to deal with these diseases. Moreover, after 1970 in vector-borne diseases the good training programs decreased dramatically. The lack of preventive medicine training in most medical schools is another important problem for vector-borne diseases. The medicinal emphasis and approximation on high-tech solutions to disease control have led health officials, most physicians and the public that is based on “magic bullets” to control an epidemic or cure an illness.

In addition, another factor is the alterations in temperatures and climate that affect the pathogen transmission effectiveness by vectors and the vectors distribution. As a result of human activities the atmospheric composition alters constantly, especially burning of fossil fuels. In addition is the plant water loss decrease and the increase of atmospheric carbon dioxide concentrations via evapotranspiration. Accordingly, plants are enhancing the density of plant foliage for elongated periods in the year, derive more foliage with the same amount of water and supplying more favourable microclimates for insect vectors. The greenhouse effect and stratospheric ozone layer increase destruction by the release of carbon monoxide, methane, halogenated compounds and volatile organic compounds together with upsurge in atmospheric carbon dioxide concentrations. In response to the raised global temperature the hydrological cycle has changed, as warm air can hold more moisture, and so did the waterborne disease vectors. Ticks and mosquitoes are excessively sensitive to climate and temperature alterations. Their reproduction, mortality rates and feeding activity are generally exactly associated with the environmental temperature. Finally was recommended that the spread of habitats of tropical insects into more southern and northern latitudes along with higher increases is induced by global warming.

Furthermore, pollution is another factor that affects global distribution of vector-borne protozoan pathogens. The Tropical Rainfall Measuring Mission satellite provide measurements, detected that both ice precipitation evolvement and cloud droplet coalescence were interrupted in polluted clouds. Also indicated by satellite data that industrial and urban air pollution inhibits precipitation. The precipitation onset delayed from 1.5 km above cloud base in pristine clouds to more than 7 km in pyro-clouds and more than 5 km in polluted clouds and reduced cloud droplet size by heavy smoke from the Amazon forest fires, that indicated by latter study. Pollution associated changes in rainfall first of all change vector environments and therefore, the distribution of correlated pathogens.

Eventually the last factor that induces global distribution of vector-borne protozoan pathogens is the insecticide and drug-resistance. The most important factors are first of all the extensive and inappropriate drug use and also improvement of genetic mutations. In the improvement of drug-resistant pathogens and vectors include vector movement and population between other factors.

For the re-development and sudden increase of diseases the potent drivers are the insecticide and drug resistance of parasites and vectors. Examples for the function of resistance Malaria spread are including in the following reports. Was latterly related from Saudi Arabia that chloroquine-resistant P. falciparum cerebral malaria inducing a high mortality rate, where previously malaria was contemplated chloroquine-susceptible. The increase in chloroquine resistance induces a significant rise in specific mortality of malaria in Senegal, Malawi and Zaire. During the previous decade when an outbreak of malaria has occurred in Chindwara in central India, the DDT-resistant A. culicifacies was found as the main mosquito species.

As a conclusion, the complicated correlation among disease drivers like global travel or weather, their financial and health impacts and modifications in pollution, are progressively being defined by research. In the last few decades, epidemiologic techniques and tools for the research of infectious diseases have refined importantly. The development of epidemic prediction, epidemic knowledge and the planning of policy analysis and efficient control provide tools for the use of geographic information systems (GIS), risk analyses, climate models and remote-sensing technologies in research. Furthermore, in the vector-borne pathogens the evolvement of complex diagnostic procedures and particularly the establishment of molecular techniques, mostly the evolution of the nucleotide sequencing and PCR, have permitted rapid, specific and sensitive diagnoses, which in turn accommodate timely prevention and exact treatment efforts. The evolution of new vaccines, chemotherapeutics, repellants, biological products and insecticides contrary to the main vector-borne diseases is critical for accomplishing control or elimination. Rotational therapy or multi-drug therapies should be employed contrary to parasites and vectors in case of the prevention of the evolvement of drug-resistance. Another preventative approximation such as biological pest control, in the protection of ticks and other vectors which are the essential need for the repellants and insecticides for example the use of nematodes, wasps, birds and entomopathogenic fungi that are safe for the environment. Programs for multi-national control and elimination have proven powerful in the battle against various vector-borne diseases comprising River blindness in western Africa and Chagas disease in Latin America. The association of global organizations, has a significant function in the funding and allocation of programs, such as the Untied Nations’ agencies constituting the WHO and World Bank. The significant allocations of the above associations have also made by public organizations such as philanthropic trusts and societies and private pharmaceutical companies. Also have been published risk evaluations and sustainability studies for future outbreak’s anticipation and then evolve the consequence of global alterations upon the transmission of diseases and the environment. Studies have been applicable by making suggestions for intervention and policies achievements. Nevertheless there is further requirement for bigger complication of international non-governmental evolvement and aid organizations. More global resources in the future, to the evolvement of prevention and prediction programs, should be appropriated to minimize or eliminate vector-borne diseases in evolving countries. It is essential that an allocated global rather than a single governmental approximation should be acted in vector-borne disease prevention.


Free Essays

How can Mental health recovery be used to inform practice and improve outcomes for patients?


The website states, “Recovery can be defined as a personal process of tackling the adverse impact of experiencing mental health problems, despite their continuing or long-term presence. Used in this sense, recovery does not mean “cure”.

Recovery is about people seeing themselves as capable of recovery rather than as passive recipients of professional interventions. The personal accounts of recovery suggest that much personal recovery happens without (or in some cases in spite of) professional help.”

The introduction of recovery and its acceptance has been a gradual process but one which has gained much ground over the last few years. It is important to consider the strengths of individuals and work in partnership with them to support empowerment. Where once a service user may have been viewed as a series of maladies and symptoms and within the context of a primarily medical model, it is now recognised that each service users is different, with differing backgrounds, abilities, aspirations, desires, protective factors etc.

The recovery model grew out of substance misuse services around the world, particularly within the United States from the 1990s. By then, long term research studies had been completed which showed complete or partial recovery from psychiatric disorders and illnesses. Kilbride and Pitt said, “The overall research findings support the concept that recovery is a process rather than an end point or a cure… It is an uneven process without a definitive end and is a relative concept, meaning contrasting things to different people.” (p.20). With the concept of recovery in mind I applied myself to thinking about an innovative service which could be provided by my team.

Many of our service users experience social isolation. It is very common when speaking with patients that they describe a cycle of low mood, leading to a decreased desire to go out and be involved in community activities, leading to boredom and lack of identity, causing further low mood, and so on. I asked the service users with whom I work what sort of service they would like to see set up and overwhelmingly they told me that they would appreciate an opportunity to increase their social contact. Some of the service users I support experience a loss of self confidence following an episode of psychotic illness and can also experience difficulties with their self image when they have experienced personal reactions, feelings and ideas which were contrary to their premorbid behaviours. Rebuilding this self image and confidence in order to take account of this new information is an important part of recovery in many cases.

I decided therefore to think about an opportunity for service users to interact socially with others. When speaking with service users I was often told that while they would appreciate increased socialisation they did not feel very enthusiastic about doing so within an exclusively “mental health” environment. I was told that they wanted to demonstrate to themselves that they were able to form social relationships with people from the wider community, rather than simply ones based on the shared (and somewhat incidental) experience of being a user of mental health services. The people I spoke with seemed to feel that it was more “normalising” to be with a mixture of people, including some who have never used services or experienced significant mental illness.

The London Borough of Southwark, where my team is based, is an area which contains much deprivation and many socially excluded young people. A study, undertaken in three areas of England, and published in the Archives of General Psychiatry, (March 2006), found that, “The incidence of all diagnoses was greater in Southeast Londonthan Nottingham or Bristol after standardization for age andsex. These differences remained after further adjustment forethnicity, except for affective disorders. This suggests truly”psychotogenic” effects of that environment or population stratificationin terms of psychosis risk and needs exploring in further detail.” They also found a large discrepancy in rates of psychosis onset and ethnic background. “The observed 3-fold increased incidence of psychoses in the BME group compared with the white British group is important, particularly because this was found across study centres and broad diagnoses. A tendency to preferentially classify symptoms as schizophrenia in BME groups cannot have led to these findings”. The implications of this and similar studies are wide ranging for the planning of mental health and social services but may be at least partially addressed on a local level by services that bring local communities together and increase individual socialisation, an aspect of life often missing from deprived, urban environments.

Kawachi and Berkman’s journal article, Social Ties and Mental Health, states “…human relations consist of multiple layers extending out from the ego. These layers extend from the most intimate relations (e.g., marital ties), outward to social networks (e.g., connections to close relatives and friends), and to “weak” ties consisting of involvement in community, voluntary, and religious organizations. Participation in the last set of ties does not necessarily impose intense person-to-person interactions. Nonetheless, it provides a sense of belongingness and general social identity, which sociological theorists have argued as being relevant for the promotion of psychological well being.” (p. 463).

There are a limited number of places where young people can get together safely and enjoy activities and socialise. I therefore began thinking about a service along the lines of a youth club. I felt it should be somewhere that young adults from the community could attend but which would also be available to service users, along the lines of not being a mental health service per se but rather being “mental health friendly”.

It was felt important that the service be removed from the team base and away from a mental health hospital setting. There is still much stigma surrounding mental illness and it is unlikely that the wider community would be willing to attend services on site.

It is important to recognise that service users may easily feel that professionals are people who have great power over them and associate the team base or the hospital with having to “behave normally” in order to prevent admission or close scrutiny. There is also the tendency for professionals to become accustomed to the caring role and they may have trouble compartmentalising this within the new service. They may be tempted to use the extra time with service users to continue their regular work with them. It is anticipated that removing the project from the associated locations may help prevent both parties continuing their accustomed patterns.

A part of the proposed service is the inclusion of an executive board, made up of a combination of staff, service users and eventually users of the proposed service. It is envisioned that the service users will be supported to plan activities and take a hands on role in running aspects of the project, such as finance, advertising, hiring of the location etc. They are best placed to advise on the needs of the local community and to identify what steps should be taken to achieve success. There is also the added benefit of increased responsibility and activity on the part of the service user which can be very therapeutically important. This approach is already used in much of mental health services and can be easily built into this project. As Hall, Wren and Kirby (2008) said, “The voice of the service user will need to be at the centre of their own care, they will be seen as the expert on their experiences, deciding on the form of their care and support, whether it is social, medical, psychological and / or educational. The mental health professional’s role will shift from the traditional role of being the expert, to working alongside service users and carers as peers in supporting them to make these choices and decisions. This will give the service user hope and empowerment for their future.” (p.115).

Another aspect of this proposed service is the ability to adapt to both external and internal changes. Over time it may be possible that, for example, the service would change to become less focused on one particular community location. Rather than meeting once a week at the same time in the same place it is possible that specialised interest groups may be formed. A photographic group may take trips around London to photograph places of cultural or historical significance, a walking group may take ‘cheap day return’ trips to the coast or countryside, or a group with an interest in film may regularly meet to watch a film and then discuss it afterwards. I envisage these additional satellite communities would be facilitated by the service users themselves, perhaps with the assistance of a member of staff when required or requested.

I have made myself aware of groups which I may be able to work with to compliment the activities this project could provide. For example there is a group in the area which have a sound studio and forging links with this organisation may enable our users to access their equipment. Also, there is likely to be a cross over in terms of the users of the various services and we may be able to market our service within these groups. Finally, it may be useful to liaise with them in terms of sharing information, learning from their mistakes and getting tips on how to run the project successfully.

The first step in setting up the proposed service would be to contact Southwark Council. They would be able to advise on issues such as requirements for Public Liability Insurance, although after speaking briefly with them I understand that most venues would already have cover, which would apply to groups who rent the space. It would be necessary however to ensure that we made certain of this when securing a venue.

The service is designed to work with young people who are over the age of eighteen. It should therefore not be necessary to ensure that special Child Protection Procedures are in place, however Safeguarding Vulnerable Adults would apply and any members of staff are likely to require a Criminal Record Bureau clearance. Our staff already have Enhanced CRB clearances but it would likely be necessary to reapply with this project specifically in mind. If this were to be the case the CRB clearance should be applied for at least ten weeks before the proposed start of the project and I would be inclined to ask for a minimum commitment of six months from any staff involved.

With regard to funding, I will naturally attempt to gain funding from the NHS Foundation Trust at which I work but I will also be attempting to locate alternative ways of funding the project. For example, I intend to approach the National Lottery Community Fund and other community based projects. I do not anticipate difficulties with this aspect of the proposal as the initial and continuing costs are likely to be minimal.

In conclusion, I have designed a project which I believe would have make a positive contribution to the mental health and social functioning of both existing service users and people from the wider community.

I have not been able to identify many obstacles in successfully launching and maintaining this project. However it is important to bear in mind that the requirement of a CRB clearance application will require a small initial expense and will increase the lead time required.There is also the necessity of locating and renting a suitable venue and ensuring adherence to safeguarding policies and more general legal requirements. None of these issues are insurmountable and should not pose too onerous a burden upon volunteers.

There would be opportunities within a successful project to develop the service and expand beyond its original operational guidelines and the flexibility in this area is one of its core strengths. The proposed service is also designed to benefit the community, which is of particular importance given that it is based in one of the most socially deprived areas of the UK. Opportunities for socialisation in a safe and what might be termed ‘positive’ way are hard to find and over-subscribed in this area of London, and from my initial enquiries, both with proposed users of this service and with existing social groups, it seems likely that demand exists.


Rethink (3 June 2011). Recovery. [Online]. Available from: [Accessed 12 July 2010].

Hall, A. Wren, M. and Kirby, S. (2008) Care Planning in Mental Health, Promoting Recovery. Oxford: Blackwall Publishing Ltd.

Kawachi, I. and Berkman, L. (2001) Social Ties and Mental Health, Journal of Urban Health: Bulletin of the New York Academy of Medicine, 78 (3), p. 463

Kilbride, M. and Pitt, L. (2006) Researching recovery from psychosis, Mental Health Practice, 9 (7), pp. 20-23

Nursing and Midwifery Council Code of Professional Conduct (2008) London: Nursing and Midwifery Council

Archives of General Psychiatry (March 2006). Heterogeneity in Incidence Rates of Schizophrenia and Other Psychotic Syndromes. [Online]. Available from: [Accessed 04 August 2010].

Free Essays

The Journey of asylum seekers and their rights to education, employment, welfare benefits, housing, health and social services in the UK


In the essay, I will be focusing on the asylum seekers in the UK. The focus of this essay is to see how their rights to education, employment, welfare benefits, housing, health and social services are exercised in the British society. I will start by defining what an asylum seeker is. The journey will consist of different stages which are first of all seeking asylum and the rights that they get with the status. The second stage will be to see how the rights change when they are granted refugee status. And the last stage will be to examine what they need to achieve in order to become British citizen.

An asylum seeker is person who has submitted an application for protection under the Geneva Convention and is waiting for the claim to be decided by the Home Office (2011). Asylum seekers should have the right to live in safety which is ultimately more important than the right to remain in one’s own community or country. When strategies have failed, and when people have developed a well-founded fear of being killed, injured or abused, they must have the option to escape from the danger which is threatening them.

The UK has an obligation under international law to protect people fleeing persecution. The UK has committed itself to the principles of universal declaration of human rights (1948) which includes the rights to seek and enjoy asylum in other countries. As signatory to the convention, the UK is responsible for guarantying that those with refugee status enjoy equal rights to the UK citizens (UNHCR, United Nations High Commissioner For Refugees, 1951).

Each individual will have his own reasons of seeking asylum. It could be that they are facing persecution for reasons of race, religion, nationality, sexual orientation, membership of a particular social group, or political opinion. In too many cases and in too many countries, people who have succeeded in fleeing from violations of human rights in their own homeland are confronted with further threats in the country where they have sought asylum.

While refugees are technically the beneficiaries of international protection, they may in practice be at constant risk of intimidation or assault, either from members of the host community or their own compatriots. Also refugee women and girls are confronted with specific protection problems, especially in the situations where established social structures and values have broken down, and where the local authorities lack the capacity to enforce law and order. Sexual violence and exploitations are some major issues, which have only recently started to attract systematic international attention (Helton, 1994). I will also illustrate an example of sexual exclusion, two gay men who said they faced persecution in their home countries have the right to asylum in the UK, the Supreme Court has ruled. Homosexuals are as much entitled to freedom of association with others who are of the same sexual orientation as people who are straight (BBC, 2010).

Asylum seekers don’t have many rights in the UK. The Reception Directive defines an asylum seeker as a non-EU national who has made an application for asylum in respect of which a final decision has not yet been taken. In the UK, eligibility for support under the Asylum Support Regulations and Interim Provisions Regulations starts when a claim for asylum under the Refugee Convention or a claim under Article 3 of the European Convention on Human Rights (‘ECHR’) has been recorded by the Secretary of State but not determined. In practice, therefore, asylum seekers who fulfil the eligibility criteria may be left without support due to delays in recording a claim or where it is disputed that a claim has been brought forward. The Home Office may in fact decide not to record an asylum claim if it is a second claim that does not disclose new evidence. Although, following a High Court judgment, the Home Office has extended section 4 (hard cases) support to such cases, it is arguable that the domestic requirement that a claim must be recorded to trigger entitlement to support is unlawful under the Directive (Justice, 2005). They have access to free health care from the NHS (National Health Service), if you receive asylum support from the UK Border Agency you may qualify for extra free healthcare such as NHS prescriptions, dental care, sight tests and vouchers to help you buy glasses.

To get this you need to obtain an HC2 certificate, which is issued by the UK Border Agency on behalf of the Department of Health and is evidence that you cannot afford to pay for these things yourself. The certificate is for you and any dependants you have. It is valid for six months. They also have the right to support and accommodation if they meet the requirements for it. They will not be provided housing in London. Very limited housing may be available in the south-east of England. While they are providing their housing, they must stay at the address they are given unless if they are given permission to move.

The UK Border Agency provides different housing at different stages of an application process. If an asylum seeker qualifies for housing when they first make an asylum application, the UK Border Agency will place them in what they call initial accommodation, which gives them somewhere to live for the first two or three weeks.

After this they will usually move to a different housing facility. It will normally be in the same region of the country as the initial accommodation, and in the region where their case owner works. Asylum seekers will not be able to choose where they want to live if they are provided housing facilities by the UK Border Agency (Home Office 2011).

Asylum seekers can practice their own religion, and are expected to show respect for people of other faiths. They are treated fairly and lawfully regardless of their race, age, religion, sexual orientation or any disability. The children of asylum seekers applicants have the same right to education as all other children (5-16) in the UK (Home office 2011). Schools commit much time, effort and resources to integrating the asylum-seeker pupils in a positive and supportive manner. Several schools have well-established and effective arrangements for the admission and induction of the newly arrived pupils and provide sound teaching support. Unfortunately, not all schools are well informed about basic procedures and guidance on the education of asylum-seeker pupils (Ofsted, Office for Standards in Education).

Asylum seekers will not normally be allowed to work while the Home Office is considering their asylum application, except in very limited circumstances. In this paragraph, it will be noted what those circumstances are. The majority of asylum applicants are not permitted to work while the Home Office considers their application. This is because entering the country for economic reasons is not the same as seeking asylum, and it is important to maintain a distinction between the two. However, if an asylum seeker has waited longer than 12 months for a decision to be made on their asylum application; under strict circumstances, the Home Office may grant them with a temporary work permit.

Currently, most new asylum applications receive a decision within 30 days. However, if an application has been rejected, the applicant may request permission to work if they have made asylum-based further submissions which have been outstanding for more than 12 months. This will primarily affect people who have already made further submissions. Anyone making further submissions now is unlikely to be become eligible to apply for permission to work (Home Office 2011).

Since 1980, 6000-7000 asylum applications per annum, by people originating from countries such as Iran, Iraq, Ghana, Democratic Republic of Congo, Ethiopia, Poland, Afghanistan, Sri Lanka (Crisp and Nettleton,1984). In 2007, 19 of every 100 people who applied for asylum were recognised as refugees and given asylum. Another 9 of every 100 who applied for asylum did not qualify for refugee status but were given permission to stay for humanitarian or other reasons (when these figures were published, 17 of every 100 applications had not yet resulted in a final decision).

In some cases, individuals are forced to remain in detention centres while the decisions are being made. Those removal centres are used for temporary detention, in situations where people have no legal right to be in the UK but have refused to leave voluntarily. Some of those detained in any of these centres can leave at any time to return to their home country. If the Home Office has refused to give a given asylum seeker the permission to stay in the UK and their appeals (if any) against the decision have failed, they must return to the country that they come from. If those asylum seekers do not return voluntarily, Home Office will enforce their removal and they may detain them until they return them to the homeland.

If asylum seekers decide that they want to return to their home country, they can do so at any stage of their application for asylum. They must tell their case owner if they decide to go. Asylum seekers should also tell their legal representative, if they have one (Home Office, 2011).

Asylum seekers also have the right to appeal which is usually called fresh claim. When a human rights or asylum claim has been refused or withdrawn or treated as withdrawn under paragraph 333C of these Rules and any appeals relating to that claim is no longer pending, the decision maker will consider any further submissions and, if rejected, they will then determine whether they can result to a fresh claim. The submissions will amount to a fresh claim if they are significantly different from the material that had previously been considered. The submissions will only be significantly different if the content had not already been considered; and taken together with the previously considered material, created a realistic prospect of success, notwithstanding its rejection (Home Office, 2011).

A question that arises is whether the UK would have to change the practice of detention of asylum seekers in accommodation centres (such as Oakington and Harmondsworth) in the light of the Reception Directive. Article 7(2) allows Member States to ‘decide on the residence of the asylum seeker’ for reasons of public order, public interest or ‘where necessary, for the swift processing and effective monitoring of applications’. This provision seems to address the Oakington justification, but it does not seem to cover detention. The provision covering detention, on the other hand (Article 7(3) in combination with Article 2, allows for confinement to a particular place ‘when it proves necessary, for example for legal reasons or reasons of public order’. There is no specific reference to the swift processing of applications. However, the provision is deliberately open-ended and non-exhaustive. The UK Government argues that domestic practice is not affected, while JUSTICE, on the other hand, argues that the provision must be interpreted very restrictively.

Those detainees can be family, single mothers, single person, foreign national prisoners who have completed prison terms for serious crime but who then refuse to comply with the law by leaving the UK (Home office 2011).

There are at least 280,000 people living in poverty in Britain after having their leave to remain refused. Some of them are appealing those decisions. Some just go completely underground, taking their chances on the streets of the UK with no money or shelter (Independent news, 2007).

The second stage will be to receive refugee status if the application is successful. From there, they will have the rights to work, to education (included university access), health, travel but they are not allowed to go their home countries until they are granted British citizen. A convention travel document issued to an adult will usually be valid for 10 years if they have permission to stay in the United Kingdom permanently (known as ‘indefinite leave to remain‘). Indefinite leave to remain (ILR) is an immigration status granted to a person who does not hold right of abode in the United Kingdom (UK), but who has been admitted to the UK without any time limit on his or her stay and who is free to take up employment or study, without restriction. When indefinite leave is granted to persons outside the United Kingdom it is known as indefinite leave to enter (ILE). If they have temporary permission to stay in the United Kingdom (known as ‘limited leave to remain‘). Limited leave to remain (LLR) is an immigration status which will allow a person to stay in the United Kingdom for a period of two or five years according each individual’s case, their convention travel document will usually be valid for the same period as your permission to stay here, up to a maximum of five years ( Home Office, 2010). Under the terms of the 1951 UN Refugee Convention, a state has the right to withdraw refugee status from any individual once it is safe for that person to return to their homeland ( Human Rights Watch,1995).

There is a waiting period before applying for the citizenship which is normally five years. They also require evidence to cover the relevant five- year period, because they will to see if you were in the country. The document which they require can be P60 tax certificates; or; an employer’s letter confirming employment; or a benefits letter confirming job seekers’ allowance claimed; or a benefits letter confirming incapacity benefit claimed; or documentary evidence confirming pension received.

If they commit an offence for example drink driving, being involved in any kind of criminal activities, the waiting period can increase to ten years.

There is a fee which must be paid in full according to the status. If you are single person and want to apply for naturalisation the fee is ?836 and for couple, its ?1294 (Home Office 2011).

There is a written test which is required before applying called evidence of knowledge of English and life in the United Kingdom and there is charge of ?35. The next step will be to attend the nationality checking service which cost ?60 for single and ?90 for couple, and can be different depending on which county council you decide to go to (Home Office, 2010). The nationality checking service is provided by local authorities (for example your county council or city council)

A local authority can accept and forward your application to us. They will ensure that your form is correctly completed, and they will copy your documents and return them to you. They will ensure that your application is validly submitted and that the unavailable requirements for citizenship are met. However, they will not give you nationality advice.

All applications for citizenship are subject to enquiries to ensure that the statutory requirements have been satisfied. Because of these enquires, we anticipate that applications may take up to six months to complete. Some applications may be dealt with more quickly and some may take longer, depending on the nature of the enquiries to be carried out.

To conclude this essay, I would to say that my view on the asylum seekers has changed. First of all, the government should change some policies about the asylum seekers because the UK is a country which respects human rights. My main concern was the way detention operates in case of an asylum case being refused. Children should not be in the detention centre. Child asylum and the detention of children for immigration purposes has been the subject of widespread media attention, and Channel 4’s Dispatches programme on Monday 29 November discussed 3 cases (Home Office, 2010). The government should make an end to the detention of children for immigration purposes, and should work with a number of charities representing children and asylum seekers to achieve this end.

My other issue is that the government should let those people who want to work while they are waiting for decision on their immigration to be made because the state losses by having to support them financially. For example, by issuing a temporary work permit, because some of these asylum seekers are intellectuals and the fact they forced to rely on benefit might create a level of low self-esteem. Citizenship’s fees should be revised as in my opinion, they are in elevation. There have undoubtedly been positives (as well as, presumably, negatives) from past patterns of immigration.

Now, however, they must focus, without the left/right prisms, on agreeing future economic migration policy. Politicians, in preparing the ground for debate, must put aside party politics.

They need to assess how many people can live sustainably in the UK, and turn our conclusions into policy. They have a finite resource: land. It is about that, and about housing, infrastructure, public services, water, and the effects of climate change, communities and government’s responsibilities to its citizens (Guardian, 2011).

BBC (2010) asylum seekers [online] available from> [ 7 July 2010]

Guardian(2010) immigration [online] available from [18 April 2011]
Helton, A, ‘ Refugees and human rights’, In Defense of the alien 1994, New York, 1994
Human Rights Watch, return to Tajikistan: Continued Regional and Ethnic Tensions, New York, 1995.
Independent news (2007) starving asylum seekers [online] available from < seekers are-left-to starve -in-britain-397576.html> [22 October 2007]
J. Crisp and C. Nettleton, Refugee Report. British Refugee Council, 1994.
Immigration and Asylum Act 1999, s 103(1). New appeal rights were introduced by the Asylum and Immigration (Treatment of Claimants, etc.) Act 2004 in two circumstances: (a) for failed asylum-seeking families refused support on the ground that they failed to leave the UK voluntarily (s 9); and (b) in relation to the withdrawal or refusal of section 4 (hard cases) support (s 10).
OFSETD (2003) asylum education [online] available from <> [October 2003]
Home Office( 2010) asylum and immigration [online] available from [ April 2010]

Free Essays

What is the relationship between personality and health?


In order to evaluate the research conducted by Friedman and Rosenman, it is important to understand the relationship between personality and health. In a study of health and illness by Bury (2005), health is an incredible riddle and hard to define but simple to spot. However, in management of health promotion and developing healthy organisation and community written by Simnett (1995) says that health approval is sunshade expression for a very wide range of performances that improve good health and well-being and put a stop to ill health. On the other hand, personality is define as psychologies with the aim of recognizing the uniqueness in human characters and understanding people’s differences in organisation (Buchannan and Huczynski, 2010).

Although, the researcher suggests that personality and health seems to be link in a way particularly relevant to organisational behaviour. However, this essay will critically evaluate the relationship between personality and health in organisation and discuss the behavioural syndromes that measures stress level in organisation. Furthermore, evaluate type A personality and B personality and also discuss how the stress levels would differ amongst the two types of personality. It would also analyse the factors and trait of the personality and suggest reasons on how these factors relate to levels of stress taken upon an individual in organisation. In addition, a discussion of the strategies management that should be used to sustain the employee stress levels and conclude.

One of the main links between personality and health involves health quality base on what individuals do. The research carried out by Friedman and Rosenman, 1974 in (Buchannan and Huczynski, 2010) shows that smoking and alcohol are relate to a number of personality behaviours such as, disobedience, ferociousness, estrangement, impulsivity, and low confidence. However, those individuals with such specific personality take bigger risk with their health and could die early. For example, it is nature and social predicament at early days that lead to drinking alcohol, smoking cigarettes and other drugs mistreatment in adolescent years (Cooley, 2009). Consequently, the rate of health inconvenience and premature death has increased significantly because of smoking and drinking alcohol. In contrast, personality has been long considering major intermediary/moderator of stress in organisational behaviour (Antoniou and Cooper, 2005). In addition, stress is a prototype of emotional states and physiological reaction taking place in response to difficulty from within or outer surface of organisation (Blonna, 2010). However, world health organisation (1992) defines behaviours syndrome as a different between people or individual in organisation. Although, the syndromes that assess the stress levels are frontal lobe syndromes that follow skull shock which adequately split in the direction of losing consciousness that include a number of different symptoms such as annoyance, vertigo, (normally lack the characteristic of true dizziness), tiredness, bad temper, and complexity. These symptoms might be accompanies by emotion of sadness or anxiety resulting from loss of self-esteem and fear of permanent brain damage in persons in organisation (World Health Organisation, 1992).

One of the strongest arguments against Friedman and Rosenman theories are the difference between type A and B personality. However, Friedman and Rosenman (1974) argued that everybody on earth has unrelated and distinctive personality. In addition, they said that each individual could be placed into one of the two personality types such as type A personality or type B personality. The Type B personality is the median. It is the normal person. They are at most times quiet and composed. It takes a lot to annoy them. They are hardly overstressed, and when feeling pressure they lean to be positive than negative. It is clearly that Type B persons do not mind driving behind an unhurried car. They do not care too much if the queue is long at the grocery store. Their velocity is calm and they are not in a rush to get things done. Type B people are patient (Friedman and Rosenman, 1974). They also state that type A personality were three times more likely to experience heart infection than type B personalities. Typical type A thrives on extended hours, large amounts of work and fixed deadlines. These are together and organisationally useful quality, as competitiveness and a high need for success. Moreover, those who are type A personality may not be able to relax extensively, stand back from multifaceted difficulty to make an efficient and comprehensive analysis, and need the tolerance and comfortable style required in some administrative positions. Furthermore, problem lies in the fact that their intolerance and aggression can increase the stress levels in those who have to work with them. For instance, a type A personality can emerge to have many venerable facets, but these behaviour syndromes can be dysfunctional for the entity, and for others. However, Friedman and Schustack, (2009:pp391) states that “the struggle of Type A person is most likely to be the one of a “choleric”, angry against the arbitrary controls of his or her job or life. Such a person will also have generally interpersonal relations”. However, there is currently high-quality confirmation that person who guide aggressive, resentfully, ready for action and ambitious lives are more likely to experience heart infection at the age of 45 than type B personality. In disagreeing with Friedman and Rosenman theories which suggest that Type B personality cannot easily get annoy and also that type A personality were three times more likely to suffer heart disease than type B, not all the type A persons suffer heart disease. For example, most people are type B, but they are not competitive, stressful, worried and hard to annoy, but have heart disease due to smoking or drinking alcohol or accident. According to Schill (2008) argue that, the type B personality loves social gathering, meeting with people, trek and be part of the groups and is often the centre of concentration. They love enthusiasm and are often impatient and difficult because of being a fattening type of personality. However, not only the type A personality is impatient but also type B personality. In addition, some persons can be both type A and B at the same time, it is irrelevant whether type A and B are related, what matters is that one person can become both type of personality. Moreover, many researchers argue that, is not only two-type of personality. A personality type is very broad and many, for example, type C and D personalities. According to Carbonell (2008) state that, type C personality is a person with cautious, competed, careful, compliant, contemplative and calculating. In clinical psychology and heart disease, written by (Molinari, Compare, and Parati, 2006) shows that, D personality type is an individual who feel anxious, unhappy, worry and have pessimistic vision of life and they can easily get irritated

The big five personality traitsThe characters
Neuroticismemotional instability, tend to be stressed, anxious, worrisome, restless and changeable,
Openness(Nightmare, aesthetics, emotion, performance, information and values)
Conscientiousness(Capability, command, dutifulness, and success determined, self-control, and reflection)
Extraversionsociability, ferociousness, action, excitement-seeking, optimistic emotion
Agreeableconviction, honesty, unselfishness, disobedience, humility, and caring, mindedness

One of the major factors in personality traits, which relate to stress level upon individual, is neuroticism. According to Eysenck in wood (1985), neuroticism are people who are highly measured on emotional instability, tend to be stressed, anxious, worrisome, restless and changeable, while those who are low in neuroticism tend to be relaxed, stay peaceful, displeasure and stable. However, other researchers analyse openness, conscientiousness, extraversion and agreeable. However, openness is one of the factors of personality traits, which indicate how open-minded a person is. There are six characters describing openness such as dream, aesthetics, emotion, performance, information and values sprint on a variety commencing traveller at one tremendous to “preserver” at the previous. The traveller (Openness+) traits are helpful for hypothetical scientists, architects, entrepreneurs, artists and modify agents. The preserver on the other hand, which is (Openness-) traits are useful for plan managers, practical scientists, theatre performers, and sponsorship managers (Costa, 1943, McCrae, 1949 in Buchannan and Huczynski, 2010). Furthermore, conscientiousness is also one of the personality traits that have traits such as capability, command, dutifulness, success determined, self-control, and reflection sprint from determined to flexible determined conscientiousness plus traits which are useful for leaders, senior executives and other high achievers, while flexible conscientiousness minus traits are useful for researchers, detectives and management consultant. While on the other hand, extraversion is part of personality traits that relate to human behaviours. The characters related to extraversion are sociability, ferociousness, action, excitement-seeking, and optimistic emotion. Lucas et al, (2000) in comprehensive handbook of personality and psychopathology written by Thomas, (2006) state that extraverts and hospitality are consequences of satisfying people in organisation. They also argued that extraverts have tendency in the direction of antagonism and power in organisational behaviour. Therefore, social behaviours in organisation are a means of satisfying the need of rewarding personality in organisation. Agreeableness is referring to human being capability to get along among other people in organisation. Agreeableness causes a number of people to become moderate, helpful, pardoning, and considerate and good nature in their communication with other people in the workplace (Griffin, 2008). He also argued that highly agreeable persons would have a superior working relationship with other colleague, contributory and sophisticated manager in organisation than those with less agreeableness. It is clear that those with high agreeable behaviour will not have fastidious good working relationship with internal and external persons in organisation (Costa and McCrae, 1992). The reason why the five big factors of personality traits relates to stress level in organisational and individual is that it contains several factors of symptoms personality traits. For example, neuroticism is one of the factors that have negative emotional unstableness, which connects to introvert-neurotic and extravert-neurotic. Introvert-neuroticism has eight characters, which are calmness, unsociable, shyness, unenthusiastic, serious, inflexible, nervous and unstable. While extravert-neurotic have eight characters as well such as aggressive, restless, quick-tempered, excitable, changeable, impulsive, optimistic and active (Costa, 1943, McCrae, 1949 in Buchannan and Huczynski, 2010).

One of the main reasons for management strategies is to reduce the stress levels on employees. Lehrer, et al, (2007) define stress management as a set of techniques used to help an individual to cope more effectively with difficult situation in order for them to feel good emotionally, improve behavioural skills and to enhance the feeling of the organisation. However, Cunningham (2000), states that stress management is define as interventions design to reduce the impact of stressors in workplace. Greenberg and Baron (2008) argued that pressure stems from many diverse factors and circumstances with the intention of eliminating it entirely from our lives. However, they state that organisations or companies still have many things to do in order to help reduce the stress level on employees. They also said that you can manage your own stress by using your time wisely, social support, eat a healthy diet and be physically fit, relax and meditation, get a good night’s sleep and avoid inappropriate self-talk. It is quite accepte for them to bring in different organized programs to help employees reduce and stop the stress levels. The reasons for these assumption is to help the employees minimize the adverse reactions to stress, so that they will be better, present, and consequently more industrious on the work which in return have positive effects on the foundation line of the organisations. It is clear that many companies in the world today have professionals in each program design to help manage the stress level of employee. The systematic programs designed to reduce the stress on employees are stress management programs, wellness programs and presents programs. That is to say, that the systematic programs designed for management is helpful to reduce the stress level on employees.

In conclusion, types A personality seem to have link with behavioural syndrome than type B. it also increase an individual stress levels in organisation. However, much research has be conduct by different psychologies with different types of personalities; argue that is not only type A and B personality, but also type C and D personality. It is hard to conclude personality type with accuracy, For example, Schill (2008) argue that type B personality is impatient while the research conduct by Friedman and Rosenman 1974 in (Buchannan and Huczyski, 2010) state that B personality are patient. Not clear which part of personality types that cause stress level in organisation and individual. The correlation data-cannot assume causal link between the variables. In order to improve Friedman and Rosenman research there is a need to identify other types of personality and eliminate stress.


Antoniou G, A and Cooper L C. (2005). Research companion to organisational health psychology. United Kingdom. Edward Elgar

Blonna, R. (2010). Stress less live more. USA. New harbinger

Bury, M. (2005). Health and illness. Cambridge. Polity

Buchanan A, D and Huczyski A, A. (2010). Organisational behaviour. England. Pearson Education

Cunningham B, J. (2000). The stress management sourcebook. New York. McGraw-hill

Cooley H, C. (2009). Human nature and the social order: seventh edition. New York. Transaction

Costa P and McCrae R, R. (1992). NEO PI-R: professional manual. Odessa, Florida. Psychological assessment resources

Friedman M, and Rosenman R, F. (1947). Type A behaviour and your heart. New York. Knopf

Griffin W, R. (2008). Fundamentals of management. U.S.A. Houghton Miffin

Greenberg J, and Baron A, R. (2008). Behaviour in organisations: ninth edition. New Jersey. Pearson Education

Lehrer M, P. Woolfolk L, R and Sime E, W. (2007). Principle and practice of stress management. New York. Guilford press

Molinari E Compare A and Parati G. (2006).clinical psychology and heart disease. Italy. Springer-verlag

Simenett I. (1995). Managing health promotion: developing health organisations and communities. New York. John Wiley & sons

Schill B. (2008). Stalking darkness. U.S.A. Brian A schill

Thomas C, J. (2006). Comprehensive handbook of personality and psychopathology. Canada. John Wiley & sons

World Health Organisation. (1992). The ICD-10 classification of mental and behavioural disorders: clinical. Switzerland. World Health Organisations

Wood C. (1985: pp12). New scientist. The healthy neurotic. 105, 1442. 7 February

Free Essays

Enhancing a Mental Health patient’s experience


This assignment is based on a patient journey encountered in my work experience as a mental health nurse, in a low secure rehabilitation unit for men suffering from a range of mental health and personality disorders, liable for detention under current mental health legislation’s. A detailed description of the patient journey will be cited in the appendix. The assignment will provide the rationale for choosing this journey. It will further critically analyze key healthcare challenges identified namely disengagement, service user involvement in care planning and how these have affected the patient and their supporters. It is important to acknowledge other healthcare challenges such as lack of community services could not be discussed due to the word limits set out for this essay. For the purposes of confidentiality, (Nursing and Midwifery Council (NMC), 2008) Clause 5, the patient name will be referred to as Michael (pseudonym).


The full description of the patient’s journey can be found in appendix


The rationale for the choice of patient was derived from my working experience as a primary nurse to Michael on the ward. Furthermore the development of better services for people with mental health has become a national priority in the UK (DoH, 2005).

It’s sometimes easy to underestimate the significance a patient might place on change like being forced to stay in hospital against their will, and miss important signs about how they are feeling. For some patients it can generate negative feelings of being incarcerated .On the contrary, detention of a patient can be perceived as progress and road to recovery by nurses (reference) Consequently increasing patient levels of anxiety if support is not provided making it difficult for nurses to engage the patient in their proposed care pathway (DoH, 2010). Wagstaff, (2011) stated that many patients equate hospital detention and treatment to imprison and lose of independence. Therefore it is important to recognise and value the benefit of listening and responding to patients experience and further recognise that the patient experience is the catalyst for doing things differently to improve the way services are delivered( Department of Health (DH),2003).

Michael expressed his frustration and felt that his life had been interrupted and having to wait indefinitely and is helpless to speed the process.

Furthermore this can impede on his chances of being reintegrated back into the community resulting in becoming hopeless.


Difficulties in engagement

Wagstaff (2011) defines engagement as adherence to treatment and professional agenda another author. Thurgodd(2004) defines it as an experience by clients of acceptable accessible positive empowering service.

The National Service Framework for Mental Health (1999) states that people with severe mental illness must engage with the services available to them throughout their stay in hospital but it can be noted that most patients do not conform to this due to bad experiences of services(Department of Health, (1999).

Therefore patients need to know that staff understand and care about how they feel (DOH,2010) but it can also mean.nurses have the responsibility of understanding

Patients in hospital may experience problems such as compliance with treatment and feelings of incarceration which poses as challenges to policy makers and staff involved in the day to day care of patients..Michael expressed his desire for independence and felt it was going to ruin his life

.Priebe (2005) found out that people disengage because they may lose their independence and sense of identity and will have difficulties with accepting diagnosis Michael reported that he had experienced poor services for long period of time both in hospital and in the community When patients get admitted to hospital they are detained against their will therefore the main challenge faced by nurses is patients requesting to be discharged despite proposed treatment working with clients general adult and old age psychiatrists often find themselves in a position where they have a responsibility to deny people freedom of choice by imposing compulsory care and treatment in the service of safety.

There have been differing perspectives on this from people who use mental health services and their advocates. Some assert that there can be no recovery as long as people are detained against their will and subject to force, others that there should be no ‘recovery?free zones’ in mental health services. Roberts et al (2008), exploring this dilemma in Advances, developed a view that compulsory care and treatment, when needed, are compatible with a recovery-oriented approach.

Person-centred approaches adopt a similar pragmatic stance. Acknowledgement of the ‘Bournewood gap’, where people with dementia have been detained de facto but without a legal framework to appeal (Department of Health 2005b), has been an important step. In institutional settings where freedom and personal choice can be heavily constrained, small choices may produce a disproportionately large contribution to well?being (Roberts 2008) and there is evidence that people can make reliable decisions about long-held preferences well into their dementia (Brooker 2007).

Paradoxically, in circumstances of incapacity (Church 2007) a high degree of restriction may be more supportive of recovery and personhood than leaving people to ‘rot with their rights on’ (Davidson 2006). Leave restrictions and detention provide boundaries to support safety planning


The service user involvement in their care is one of the statutory requirements by the NHS and Community Care Act (1990) and The Health and Social Care Act (2001). Additionally the National Service Framework (1999) and the Care Programme Approach (1991) set standards for mental health services and emphasise on the need for user consultation and involvement. As a result the writer realises the importance of involving patients in decision-making about their care to be good practice. One of the concept of clinical governance is that the patient should be at the centre of their health care, meaning that the individual will actively be engaged in all stages of the decision making process ( Funnel, 2003)

The concept of service user involvement is broad and difficult to define as stated by (Simpson et al, 2002). It can be very difficult or in some cases impossible to complete the assessmentforms for a variety of reasons. A person in care, especially if being detainedagainst their will in hospital, can be physically violent, may seek to abscond, and may initially refuse to engage with staff. Some, although not actually violent, can be verbally aggressive and uncooperative in answering questions.These situations are common and understandable in people who are being compulsorily detained or treated against their will. Their admission can just fuel their anger, suspicion, and sense ofinjustice. From previous experience using the principles and practice of the TM, however, untoward or violent incidents are far less common when wepersevere in trying to relate to difficultservice-users and, throughperseverance and goodwill succeed in doing so.11The sooner the person in care feels understood, the sooner he or she will calmdown and become more trustful and co-operative. Of course, the necessaryprecautions have to be taken to make sure no one gets hurt before this happens.Other service-users cannot relate initially because they are so distressed ,confused or preoccupied with their own thoughts and feelings. They may not be capable of giving coherent answers to questions at this stage. Some may be willing or even eager to talk but have such bizarre thoughts that their answers seem to us unintelligible. These ideas may be considered psychiatrically delusional. But it must be remembered that these ideas are real and very important to the person. It is helpful to accept their validity and imagine what it must feel like to hold those beliefs. These can then be better understood and discussed.

The benefits of service user involvement stem from the view of service users as experts in their own experience of mental disorders and the services offered (National Institute for Mental Health in England, 2003).The National Schizophrenia fellowship (1997) are of the notion that user involvement should improve the professionals better understanding of the impact of mental illness on users, better targeting of services with a knowledge of effective interventions and increased compliance with treatment by users. However Barnes and Bowl (2001) argue, that “user involvement is not a clinical intervention technique”(p95). On the other hand Priebe and McCabe (2006) also state that involving users in planning care may help the professional and user develop a therapeutic relationship.The NSF (1999) stipulates that all service users should be involved in the planning of their care and should have a copy of their care plan. Ryrie and Norman (2004) describe a care plan as a process by which the nurse arrives at a shared understanding with the patient of what the problems/needs priorities to be taken and provides details on what should be achieved. Care plans should identify a client’s specific need including actual and potential problems, measurable goals to work toward for each problem, realistic approaches to reach each goal, time frames for reaching and re-evaluating goals, and individuals with the primary responsibility for each approach (Ryrie and Norman, 2004). Fox (2004) suggests that care planning provides a road map of ways, to guide all who are involved with a patient’s care. Since assessing anyone’s mental health problems depends almost totally on the person’s account of his/her experiences, this account is seen to be very important. The person’s experiences are unique to them, and known completely only by the person themselves. When someone has mental health problems, they often have extreme or upsetting life experiences, that are preventing them functioning in their current situation

Very often, there is a threat to self, the heart of our life experience .Very often the person becomes isolated even from friends and family. It is only by drawing close and listening to their “story” or the account they give of themselves and their experience that we can begin to understand, work out with them what might be done to help.(

The CPA and NSF standard 4 calls attention to involving service users to their own care and view it as managing and co-ordinating care (NICE, 2002). Peck, et al (2002) states that when service users are involved in drawing up their own care plans leads to a positive outcome. However, Webb et al (2002) in a survey to evaluate the implementation of CPA found that the service users were not involved in the care planning procedure and did not have a copy of their care plan. Rose (2003) found that most service users did not understand the CPA process and they were not aware of how care is coordinated and were not involved in the care planning process. Dougherty and Lister (2004) state that clinicians should recognize that the client is the expert regarding their own health care needs; therefore it is important for the clinicians to plan

The National Service Framework for Mental Health (1999) states that people with mental illness must engage with the services available to them However, despite the availability y of many treatments for patient group many avoids them (Sainsburys Centre for Mental Health 1998).The importance is to create a relationship that allows the patients to share their experiences whilst receiving treatment to improve their quality of life.

Lack of services

When the courts order hospitalisation of a patient for treatment it may be argues that the court is concerned more with the therapeutic interventions that focus on the reduction of risk to the public than with the client individual treatment needs(START,2004)Although safety is of paramount it needs to be recognised that individuals can become institutionalised in the system impedeing their journey to recovery.

CONCLUSION (approximately 150 words)

Barker P (2001) (b) The Tidal Model: Developing an Empowering, Person-Centred Approach to Recovery Within Psychiatric and Mental Health Nursing, Journal of Mental health Nursing 8, 233-240
Maureen Smojkis (2008) PERSON-CENTRED & COLLABORATIVE MENTAL HEALTH CARE (Using the Tidal Model) TURNING THE TIDE HANDBOOK The Centre of Excellence in Interdisciplinary Mental Health University of
Birmingham & Birmingham and Solihull Mental Health NHS Trust
(Nursing and Midwifery Council (NMC), 2008)
Doh, 2005 National Srvice Framework 5years on . Doh, London
Thurgood M 2004 Engaging clients in their care and treatment.In Norman I,Rye Ithe art and science of Mnetla Helath nursing.Atextbook of princeples and practice.Open University Press Maidenhead.
Sainsbury Centre For Mental Health(1998)Keys to engagement:Review of Care for People with Severe Mental Ilness who are hard to engage with services.SCMH.London.

Free Essays

Health tourism and its impacts on host nation and hospitality industry


Growing demand for health services is a global phenomenon, linked to economic development that generates rising incomes and education. Demographic change,

especially the ageing population and older people’s requirements for more medical services, coupled with rising incidence of chronic conditions, also fuel demand for more and better health services. Waiting times and/or the increasing cost of health services at home, combined with the availability of cheaper alternatives in developing countries, has lead new healthcare consumers, or medical tourists, to seek treatment overseas.

This booming growth for medical/health tourism in recent times has had both positive and negative impacts on the global healthcare and on the host nation. Whether health is a motivator to travel or as a contributor to disease transference it can have a great impact on the hospitality and tourism industry. It can influence social, financial, industrial, environmental, business and hospitality sectors in an economy. It’s impact on global healthcare can lead to innovation in healthcare solution, enhancements in healthcare solutions, enhancements in the number of healthcare professional, increased international standards in healthcare solutions and emergence of supporting healthcare infrastructure for example a medical hotel.

A number of tourists are now combining vacation and health care. According to Travel Health Watch (Oct 18, 2010) medical tourism market shows rapid growth. The 2010 Portrait of American Travellers, a study compiled by Harrison Group and Y partnership, found that half of leisure travellers from theU.S.are familiar with the idea of medical tourism. The study also found that the medical tourism market is growing 20 percent each year and leisure travellers will consider having a medical procedure done in a foreign country if they could save some money, the quality is comparable to services provided in the U.S, and/or if their insurance would not cover a particular procedure in the U.S.

In India, health care is one of the largest sectors, in terms of revenue and employment, and this sector is expanding rapidly largely due to health and medical tourists. During the 1990s, the Indian health care sector grew at a compound annual rate of 16%. Today the total value of the sector is more than US$34 billion. By 2012, India’s health care sector is projected to grow to near US$40 billion (PricewaterhouseCoopers 2007).

Medical hotels are also in the rise due to the demand and rapid increase in health care from tourists. Consortiums inSingaporeare investing in medical hotels which will boast a 260-room luxury high-rise connected to the east wing of a new hospital inFarrerPark. The hotel will feature a 500-seat conference hall, indoor and outdoor gardens and a spa, as well as a dialysis machine and other medical equipment for patients who don’t want to stay in the hospital. It will add new meaning to the concept of a healing holiday.

Jetting off to a foreign country for affordable cosmetic surgery has been a popular option for years. But now, pinched by rising health-care costs in developed countries, travellers are going abroad for routine required surgeries and procedures, including colonoscopies and ob-gyn exams. According toButler,Sana, by 2012, experts predict, medical tourism will turn into a $100 billion international industry with more than 780 million patients seeking health care abroad.

Travelling overseas for medical care has historical roots; previously limited to elites from developing countries to developed ones, when health care was inadequate or unavailable at home. Now however, the direction of medical travel is changing towards developing countries, and globalization and increasing acceptance of health services as a market commodity have lead to a new trend; organized medical tourism for fee paying patients, regardless of citizenship, who shop for health services overseas using new information sources, new agents to connect them to providers, and inexpensive air travel to reach their destination.

Health tourists constantly prefer to consult doctors of high repute, whose skills have already benefited patients with similar medical conditions. The enormous need for proficient personnel breeds more specialists who cater to this escalating requirement thus contributing to the economy’s employment. Apart from the physician’s status, a potential foreign medical tourist looks at numerous other aspects of the medical establishment, to which he/she entrusts their wellbeing. As per industry standards, accreditations from authorized bodies are recognized and accepted. Other variations which monitor quality and accountability standards are also improved upon and utilized. National accreditations, which have their own stringent parameters, are also improving upon international standards to meet international patient requirements and expectations.

Dispensation, storage & interpretation of available medical records and data files; a process termed ‘Knowledge Processing’ has made the medical system transparent beyond medical authorities worldwide, to respective patients as well. Prior to the global focus on health tourism, the importance of this process was not felt as keenly as it is today. With the advent of the internet and web conferencing, medical proceedings, subject data and case histories of patients around the world is now available and shared online with doctors operating in any country. It provides them with excellent opportunities to interpret, assimilate, improve, collaborate and enhance the overall health services afforded.

Globalization of medicine has brought the emanation of several other allied international sectors like healthcare insurance, vast selection of tourism getaways, varied choices of travelling and unlimited options for hospitable lodging in the country that one chooses to get treated in. Besides, the banking sector has facilitated advancing of loans, comfortable payback schemes, credit card facilities; easy access to internet payment gateways, abundant foreign currency exchange centres and other painless international banking procedure to help foreign tourists. Such programs have completely ruled out affordability or inaccessibility to capital, as a hindrance to disease alleviation. For many nations obtaining medical visas is now an effortless procedure.

When established as an industry, medical tourism is significantly instrumental in moulding the society of a nation. It contributes not just in terms of enhanced, speedier or affordable healthcare, but also lends itself to infrastructural betterments, more employment opportunities with an increased propensity towards overall wealth creation. In nations that are still in the developing stages, such improvisations pave the way towards industrial growth to cater to the burgeoning demands of the foreign health seekers. A developed nation, on the other hand gains prominence as a popular healthcare destination and people start travelling there for medical attention.

According to Weaver and Lawton (2010) manufacturing industries, foreign investments, business exports, agricultural, mineral products or information technology services, are currently among the most prominent and largest contributors to any nation’s Gross Domestic Products (GDP). Therefore, medical tourism will soon top the charts as a key money grosser, contributing significantly in the GDP for a nation which affords such facilities. As more tourists arrive into the country for cheaper, better and faster remedy for their illnesses, the chances of financial gain is guaranteed.

All medical tourists do not visit a country with the express purpose of a treatment or surgery. They also intend to tour the country’s other historical or natural attractions. This trend is growing as tourists tend to invest the amount they save in healthcare, during sight-seeing. This serves as significant revenue for the tourism industry and forms a portion of total profits of the industry.

Another industry very closely associated with the field of medical science is the pharmaceutical industry. When one undergoes treatment or surgery in one country, they are bound to take over-the-counter drugs sold in the same area. This increases the sale of medicines in a directly proportional manner such that, the number of surgeries or treatment conducted directly adds to the profits of the pharmaceutical company of the country that is a prominent medical tourism destination.

The medical tourism industry is served both by private as well as public sector industries. While the public sector contributes to the overall infrastructure and associated processes like permitting medical visa, clearing foreign passports, facilitating foreign exchange etc; the private sector totally takes over the comfort & hospitality department as well as the healthcare facilities. The kind of medical care and amenities provided by private sector industries is generally far more superior to that offered by government establishments. Under such situations, a public-private partnership tends to equalize profits, adds to overall infrastructural benefits and caters to the needs of the foreign medical tourist, in a balanced manner making the overall procedure smooth, rapid and economical. For example The Indian Ministry of Tourism has started a new category of visas for the medical tourists. These visas called the “M” or medical-visas are valid for one year but can be extended up to three years and are issued for a patient along with a companion.

A country that prospers in the healthcare tourism industry will also experience fewer exits of trained professionals from their home country to a foreign nation availing better employment and financial opportunities which is prevalent in developing countries in Asia,South Americaand South Pacific. Medical professionals are content as they get the required job satisfaction and financial fulfilment even when stationed in their native country.

There are also political advantages as well when one country serves as a major tourism destination for another and there is constant exchange of treatment and revenue between them, the political links between those nations are affected in a positive manner. Stronger bonds between those nations are forged when the host nation and provide the foreign tourists with several amenities besides conducive medical treatment.

Along with the positives there can also be some negatives impacts associated with health tourism. With patient travels; there is significant risk of corresponding bacterial travel. All industry professionals must understand the negative impact of communicable diseases. Hence, good strategies should be developed by global organizations to protect spread of such diseases. Understanding and control is vital for all the countries involved.

.For infrastructural growth, the natural greenery or forest cover of a region is compromised in order to accommodate more buildings, hospital facilities, roads, treatment or diagnostic centres etc. To supplement the above, there is a continuous discharge of polluted air, solid -toxic medical waste, litters of sewage consisting of oil and chemicals. Architectural, noise and visual pollution also has a direct negative impact on the atmosphere.

Health tourism also creates a dearth of local resources like power, food stock, fuel and other unredeemable natural resources, which could already be in short supply within the host country. Water, another non-replenishable natural resource, is commonly misused in hotels, spas and swimming pools through careless personal use by tourists. This not only generates large volumes of waste water but also leads to water shortages and depletion of natural water sources.

With an increased number of health tourists, the hospital/hotel adopts the policy of being paid in accordance to an overseas system. Such a structure, even though economical to a foreigner, tends to be expensive for the native. As a result, all sections of people within a particular nation are not able to take advantage of the advanced treatment options available within the country. This creates a negative impact on the health infrastructure of a country.

Healthcare tourism in most countries runs through private institutions. Currently the private sector in most developed countries accounts for a larger number of surgical procedures, treatment operations, and ultimately in the overall number of patients from all over the globe. Thus the revenue generated by this sector is much greater compared to that generated by the government or the public sector. The uncontrolled growth of the private sector can lead to inequalities and profit imbalance across both sectors.

There are significant chances that many medical tourism hospitals would tap into unethical practices to grab international patients, such as organ transplants, restricted regional treatments or several other medical services which are restricted, regulated or controlled in one region. Legal issues are also likely to rise as the health industry presents unique problems and challenges for both consumers as well as providers.

Both positive and negative impacts of medical tourism on healthcare, economic, social and environmental sectors creates opportunities and challenges for this growing industry which require cohesive collaborative work between various stakeholders.

Medical tourism doesn’t only provide benefits to international patients or health/medical tourists but it extends to a wide spectrum of benefits to many industries such as the healthcare industry, travel and tourism, commercial sector, government relationships, and international accreditation sector. There are also negative impacts medical or health tourism can have by attributing to shortages of scare local resources in energy usage including electrical power, food stock, fuel and other unredeemable natural resources such as water and the resultant environmental issues which needs to be considered and controlled by governments of countries in midst of this global phenomenon.

Reference List

Butler, S, 2009, ‘Holidays for health’, Newsweek International viewed 26 May 2011, pp.36. Available from: .

Carrera, P, Bridges M, John F, 2006, ‘Globalization and healthcare: understanding health and medical tourism. Expert Reviews. Vol. 6, Issue 4, pp.447 – 454.

Dr. Prem, J, 2010, ‘Medical tourism impact its more than obvious . Medical Tourism Magazine vol 17, viewed 26 May 2011, Available from: .

Hazarika, I,2009, Medical tourism: its potential impact on the health workforce, Oxford Journals, vol 25, no 3, pp.248 – 251, viewed 26 May 2011.

Mathieson, A and Wall, G, 1982’ ‘Social Impacts’, in Tourism: economic, physical, and social impacts, U.S ed, Longman,London.

McKerchera, B, 1993, ‘Some fundamental truths about tourism: understanding tourism’s social and environmental impacts’ Journal of Sustainable Tourism [online]. viewed 26 May 2011, pp.6 – 16. Available from: .

Otley, T, 2007, ‘Patients without borders: it is now cheaper and easier than ever before for patients to receive good-quality healthcare abroad, but how is this medical tourism affecting the host nations’?(Fit to Fly: Medical travel)’ Business Traveller vol 2 viewed 26 May 2011, pp.36. Available from .

U.S. House, 2007, Market report for Healthcare in India, Government Printing Office,Washington.

Weaver, DB and Lawton, L 2010, ‘Economic impacts of tourism’, in Tourism management, 4th ed, John Wiley,Qld,Australia.

Free Essays

Post-emergency phase health plan for Beravania


Republic of Beravania is victimised by man-made and natural devastation. Such emergencies are responsible for immediate and long term effects in low income countries. In addition to deaths due to such catastrophes, disruption of the basic services such as shelter, electricity, water and healthcare leads to increased morbidity and mortality amongst the victims during and after the calamity (Kruk et al., 2010, Jean, 1999).

Considering the country profile for Beravania and the information available, this is a strategic national health plan for post emergency situation for 2009-14. It is divided in two parts. In the first part, the current situation is analysed and four broad areas of priority health needs are identified and justified. In the second part strategic approaches have been recommended to deal with this priority health needs and further appropriate interventions are planned.


Republic of Beravania is an ancient country victimised by man-made and natural catastrophes. These emergencies have worsen the poor health status of the population to such an extent that it could not recover till date. The deteriorating health status of the people especially of the vulnerable group (children and women) call for an urgent need to concentrate the efforts of national and international agencies in planning and strengthening the current health system by a need based health plan for the country.

Country has subtropical to cold climate with moderate to heavy rain. Inspite of that there is great constraint in access to clean and safe drinking water to majority of population due to poor infrastructure for storage and supply causing direct impact to the health and physical development of the people especially children. Beravania is one of the poorest country facing great economic difficulties, political and ethnic crisis that further depreciate the situation.

Analysis of health indicators of the population reveals that there is very high infant as well as under five mortality rate. The leading causes identified for mortality are diarrhoeal disease, acute respiratory infection, dengue fever, vaccine preventable diseases, and protein-energy malnutrition and micronutrient deficiency. Communicable diseases such as HIV, TB and Malaria are a great threat to all age group causing high rate of morbidity and mortality. Disease surveillance system is comparatively well-organized and functional. Health service delivery is inadequate, inaccessible and unaffordable for such a large population due to human and financial resource constraints and unequal allocation of available resources.


The key priority areas identified based on the assessment information for health plan are:

1) Food Security and Nutrition

Food shortage and malnutrition are common problems during and after emergencies. Food shortage occurs mainly due to unexpected substantial decline in food availability and accessibility (Korf, 2002, Jean, 1999). In the current scenario, despite of good climate and rainfall suitable for fairly good amount of food crop production, food shortage and malnutrition are most prevalent due to urbanisation, socio-economic reforms, civil conflict and natural calamities like flood and famine (Messer, 2001).

It has been proved by various researches that prevalence of malnutrition is much higher among these people as compared to common population. Protein Energy Malnutrition and micronutrient deficiency are commonly identified nutritional problems which are major cause of increased morbidity and mortality in these situations and similar pattern is observed in Beravania also (Jean, 1999). Improving the nutritional status has a positive impact on health status, resistance to disease and psycho-social well being which justifies it to be on the priority list.

2) Health Service Strengthening

Post emergency period is most convenient for improving the healthcare services that has been ruined by the catastrophes. Healthcare is a basic necessity and so during emergency main focus is on quantity of health service provision while in post emergency adequate health service provision and strengthening is important to be considered. Health services established during emergency phase can be reoriented, restructured and reinforced based on needs assessment (Alonso, 2006).

In the post emergency phase healthcare programmes requiring stable circumstances with long term treatment and follow-up such as T.B, HIV, Mental health and maternal and child health programmes can be restructured and implemented effectively (Kruk et al., 2010). Community health services can also be reorganised.

3) Communicable Disease Control

There is an increased risk of epidemic of communicable diseases even in the post emergencies period. Some of the common contributing risk factors are deprivation of basic needs such as food, clean drinkable water, healthcare as well as increased risk due to deficiency of nutrition and immunity, lack of shelter, sanitation and hygiene. Communicable diseases are primary cause of disease related morbidity and mortality during these situations. Most prevalent communicable diseases during this situation are diarrhoeal disease, acute respiratory infections, T.B, HIV and malaria (Speigel, 2004). Similar condition is observed in Beravania in the post emergency phase. Hence it requires an immediate attention.

4) Water, Sanitation and Hygiene

Water is the basic necessity that is impacted severely during emergencies and even in post emergencies if problem is not resolved by long term sustainable alternatives. “Water and environment plays a major role in spread of communicable diseases and epidemics” (Jean, 1999). In Beravania in-spite of having good rainfall it is facing scarcity of clean drinking water and also spread of diarrhoeal disease which is one of the leading causes of child morbidity and mortality post emergency. Hence it is considered as a priority for planning and maintaining minimum risk threshold for water, sanitation and hygiene related morbidity and mortality (Richards, 2004).



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JEAN, R., E. SONDROP, F. VAULTIER (ed.) 1999. Refugee Health – An approach to emergency situations.

KORF, B., E. BAUER. 2002. Food Security in the Context of Crisis and Conflict: Beyond Continuum Thinking. Gatekeeper Series No.SA106, 1, 1-25.

KRUK, M. E., ROCKERS, P. C., WILLIAMS, E. H., VARPILAH, S. T., MACAULEY, R., SAYDEE, G. & GALEA, S. 2010. Availability of essential health services in post-conflict Liberia. Bulletin of the World Health Organization, 88, 527-534.

MESSER, E., M.J. COHEN, T.MARCHIONE. 2001. Conflict: A Cause and Effect of Hunger. In: ECSP (ed.).

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SPEIGEL, P. B. 2004. HIV/AIDS among Conflict affected and displaced populations: Dispeclling Myths and taking action. Disasters, 28, 322-339.

Free Essays

Crisis and acute care in mental health: the nature of risk and risk assessment in relation to suicide


The purpose of this assignment is to demonstrate an understanding on the nature of risk and risk assessment in relation to suicide. There are a number of risk assessments used within the field of mental health, but for this assignment we will focus specifically on evaluating the actuarial and clinical approaches when assessing suicidal clients. To conclude it will explore some of the challenges that nurse faces when assessing suicidal clients in crisis and acute care settings.

It is well established that people who have mental health problems are a high risk group for suicide (The National Suicide Strategy for England 2006). Primarily these are people who have experienced depression, alcohol disorders, abuse, violence, loss, cultural and social background (WHO, 2011). Suicide is recognized as a serious and global public health problem. It is among the top 20 leading causes of death globally for all ages. It has been identified that a significant number of suicides occurred during a period of in patient care (Bertolote et al, 2003).

The Department of Health (DOH 2002) issued the report saving lives: Our Healthier Nation and set clear targets to reduce the death rates by suicide by at least a fifth by 2010. The national strategy highlighted that there needs to be a systematic approach to reduce suicide. Standard 7 of The National service framework for mental health (DOH 1999) emphasises on local trusts to implement policies to reduce the rates of suicide. All individual Trusts have developed a toolkit to work towards a trust wide suicide prevention framework. According to Morgan (2007) mental health services have become ‘operationalized’ through practice guidance from a central theme in the National Health Service’s National Service Framework (DOH 1999) and provide a particular emphasis on Care Programme Approach ( DOH 2008 ). Anderson & Jenkins (2006) argue that although comprehensive strategies need to be in place the rate of suicide continues to be a concern. However recent figures show there has been a decrease in suicide rates in mental health patients particularly among young men in in- patient settings (National Confidential Enquiry into Suicide and Homicide by people with Mental illness 2010).

Risk assessment and risk management are concepts that are very familiar to mental health nurses and it encompasses the majority of nurse’s work. However Crowe & Carlyle (2003) argues these are taken for granted as a necessary and an unavoidable role within mental health nursing as they defend nurses against potential litigation. According to Tummey & Turner (2008) the notion of risk has arguably displaced care when defining the purpose of patient contact. Beck (1999) suggests that risk assessment in the mental health care setting is an attempt to control the behaviour of patients and clinicians for the interests of the organisation rather than the best interest of the patient.

There are three types of risk assessment: the unstructured clinical approach, the actuarial approach and the structured clinical approach (DOH, 2007). Historically mental health practitioners used the unstructured clinical approach this was guided by intuition, experience and individual judgment to determine the severity of risk. This approach has been criticized for being, unstructured, informal, and subjective consequently leading to a lack of consistency and reliability. (Turner & Tummey, 2008).

The drive to towards evidenced-based practice as a more objective and reliable means of risk assessment has led to the development to the actuarial risk assessment tools (Tummey & Turner 2000). This approach was derived from the insurance industry; it uses mathematical means to establish the outcome. Actuarial risk assessments are based on statistical probability they produce an estimate of risk collated form group data. They attempt to predict an individuals risk based on their future actions and look at the behaviour of others in similar circumstances (Hart & Kirby, 2004). According to Szmukler (2003) the actuarial approach eliminates the problem of the subjective clinical judgement and focuses on the actuarial risk assessment to form that decision making process. Tummey & Turner (2000) argue that an actuarial approach can create a false sense of expertise within clinicians particular for those who are less experienced. The scientific validity of this approach is open to criticism, Hart & Kirby, (2004) argue that humans act in very individual and unpredictable ways so therefore the scientific principles do not work. Bouch & Marshall (2005) recognises that the problem with this approach is that it focuses on the statistical outcomes rather than on gaining an understanding on the severity and the circumstances of the suicide. Silver & Miller (2002) affirms that an actuarial risk assessment is more useful in labelling an individual rather than understanding why they are behaving in a particular way. According to Turner & Tummey (2008) actuarilism reduces an individuals risk to a range of inconsistent variables encompassed within a series of tick boxes. Research findings that support an actuarial approach over the clinical approach are controversial and cause considerable debate. Little child, B & Hawley, C (2009) suggest that there must be a mix of actuarial and clinical risk assessments to aide the clinician to gain a thorough risk assessment.

The structured clinical assessment utilises both the actuarial and clinical approaches. It draws on the science of actuarial approaches but attempts to take advantage of an informed clinical judgement through patient assessment (Conroy & Murrie, 2007). According to Doyle & Dolan, (2002), this approach is person specific and is based upon gaining the individuals history; present mental state and other relevant information to establish the risks for the individual, gathering this information is imperative due gain a thorough risk assessment. Structured clinical risk assessments are evidence-based, transparent, and flexible, and are aimed at establishing a collaborative approach (Haques et al 2008). Crowe & Carlyle (2003), reports that structured clinical risk assessessments aid clinicians to avoid missing potential information as they provide a way of organising clinical thinking. However risk assessments are only as good as the information they include and it is also dependent on the skills of clinician carrying out the risk assessment (Harrison et al 2004). Evidence suggests that there are no research instruments, scales or scores that can predict the risk with total accuracy it recognises that a combination of actuarial and clinical approaches enhance the dynamic and continuous process of risk assessment (Doyle & Dolan, 2002). It is evident that the majority of research suggests that a risk assessment should encompass a mixture of an actuarial approach with a clinical approach to form the bases of a validated risk assessment tool.

Beck et al (1979) developed a classification system of suicidal behaviours, and assessment scales to assess suicidal intent. According to Anderson & Jenkins (2006) these assessment scales are an accepted, reliable and valid method used by professional’s world wide. The Beck Suicide Intent scale (SIS; Beck et al 1974) is a 15- item questionnaire designed to assess the severity of suicidal intent associated with an episode of self harm. Each item scores 0-2, with the total score ranging to 30. It is divided into two sections: the first 8 items focus on the circumstances of the act (such as planning and attempts to avoid rescue). The remaining items are part of the self report section this is based on the patient reconstruction on their thoughts and feelings at the time of the act. Harriss & Hawton (2005) carried out a study which looked at 4,156 deliberate self harm patients between 1993 and 1997.It concluded that the suicide intent scale could not predict who would commit suicide but noted the information gained about ideation and intent would be useful in a clinical risk assessment. Suominem et al (2004) argues that the scale is time consuming therefore a shortened version of the scale would be far more beneficial to use in clinical practice. Research suggests that this scale has some weaknesses over the value of self report. There may be bias within this section due to the fact that people may be ambivalent when answering questions regarding self harming and suicidal intent. Their reflective account of the situation may not be a precise therefore it is difficult for the clinician to gain the correct information to use within the risk assessment tool (Barker, 2004). Risk assessment can have differ in results when different professionals complete them therefore the risk undoubtfully weakens the reliability on risk measurements with all risk tools.

Competent risk assessment, communication and management within an acute mental health ward can be a major challenge for nurses, irrespective of their experience (Harrison et al 2004).



Risk assessment continues to be a complex and


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Bouch, J & Marshall, J (2005), Suicide risk: structured professional judgement, Advances in psychiatric treatment, Journal of continuing professional development, Vol 11 pg 84-91.

Conroy, M & Murrie, D (2007), Forensic assessment of violence risk: A guide for risk assessment and risk management, John Wiley & sons, New Jersey.

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